GW1-2022-10653_Well Construction - GW1_20221128

WELL CONSTRUCTION RECORD For lacmi Use ONLY:.
ihfs form can,be nwil for single or multiple iviclis
"W�AVATLIKZONES
Brian Ewing
4240-B f4 m.
NCIVellCoidmciorCcrtifi=ionNiiwhct _35,OUTER CASING Mir iohHi cased iscRsi OR LINERAf ai)
FRom R THICKNESSYORtAl.
SAEDACCO Inc
46.INNFR CASING OR-TU c er
FROM TO D1,10—-----I ..
"i fit TMMNFSS I MATERIAL
2,Welt-Congjigerij,VCITuit 70003075 0 ft, 5 ft, 1" '11L SCH-40 PVC
Iiii Jill amilirable will pervh.lii Ox-coulay.Shve,
ft. ft. hL
3.*WicI1__lisp vfSq)': -17.,SCREEN
Water Supliky%19•lj- FROM. To BIANUK.TPR ST,OrS'V?#', I T1uCX1NFZ5 I MATMIAT,
5 15 1 fit .0 40 PVC PRE-PACK
13Agricultural ENtinicipal/publi'C
C3Gcotkmiat"(He-itingiCooiiijg-Sul)ply) ®Residential Water Supply(single) ft. ft;
Oludustrial/Contatcrcial Mesidendal Wamr.Supp!y,(shared) 71&GRO1lJT_.
FROM. - TO. MATERML EMPLACEMENT NIMOD&AMOUNT
❑IiTipalion R. A.
Nou-NKOFStipplyWpit:
ft, ft.
tldlvlptiitniing [Mmki-cry
Injection Well: ft. ft.
00kituidmilcir 19.1 SAN DI GIUVE L PA C K I le)-,
-WHOM _T R.mP1,%Cf'.%1KNT ML-Illan
I]AOfter'St6ragc and RccovCiy pSalivifty-13irricr 3 '15 R. (11, FILTER SAND # 2
E3 Aquiirci Tcit. 13 S 4 6 inti%-j t C e b q 11a"a g'Q
13 Expc rimcnital'rMur ilog%
2fl.,DRILLINGIOGIat1jeft iddiflorkil sheets if ncc6uni
E30eeffigrural#Aused Luopi, 3tri e a FRO"it To DRSCRIPTION(mbr.h virdo m vj'Vtnk ilypt.'»rjii"wv.6_1
ElGeaffientiat(BeatinpJCool-in?RCLUHI) 130ther(explaiti,under.421 Retuar.ks) 0 It. 10 It, FILL SILT AND SAND
10 If. 15 tL MOIST SILTY SAND/WET
Wells)Qdpiplece ! 10-27-22 well ED#TMW-7
4.Date d.
F
$a;Wdl Location..
City of Charlotte ft. ftNOV 2 8 2022
FhcilftylpivncrNn Facility ibg tjfqpiicabtc) -
I n, m formi, V n m 'r" -- -I rL,333 Parkwood Ave., Charlotte, NC, 28206
PhjiW,,Ad4i-.ss.CiLy-nd Zi 21.REMARK$
Mecklenburg 08301126 BENTONITE SEAL 2 TO 31'
counly Mire]U-nifirwationNo.(PIN)
mv..-I*itude,iiind Lo-rig-it,ttilc in dcgreesliniiiutesJmceonds or ftimal acgrim".
22.Certification:
N w- —8-dan-EW 11/9/2022
Sijuatum b1fCcriffind WcH Contractor,, Dafe
6.is(tip)the well(s)r OPentlaiment of ZTemporaty
Hy Nivi"s lUtpim.I hereby iverfify tittir 1hr m-efl(s)ma fwrrrJ carss7rucrrrr br;i.twordancr
idih 15A XCAC 01C Ohn or IJA XCAC 0k.0204 Well Consmirrim Sm1warAs acid Am d
7.h,tELis a m047 fu ad Astixq-welk Mm or ENo
ljrhfs
rqw,. Site' diagrank or additional svill details-
Y,5u may use&back of this,page,io'Ploilid--;idcUtioiiaI ivell site details.-or wME
S.Nnutberofiivellsmustmied: 1 consituctiondetails, You inay:iLii'aflacli:iddiliotln!pits if tnxcssary.
For mtmldple Irdecrion' mi ora -irwer supply ivel4s ONLY f4rh dlttsrrMPSnlrstri{�(tolr,-yoar cm
sabvjiifone.forrv. SUBMITTAL INSTUMONS
0:'Total ivrl I depth be[oiv land mirface: is, .244 Par Att WA Subutit tliis forin within 30 days;of compicii6p or wen
'�elh lisr ail ifefion ifdifferem;(eTC'0jPje_J@209'tTfWr2 qJ jOrl)For mildple cons(niction to the folloning:
1.0.Statiovater lievet below tapareasing. (ft.)
bivisiumi ui Water R�qo_tort6.InfiPirmadd12 P'tucessing Unit,
. '16.0mlit$effiq_00:gter,Raleigh NC 27699-1617
r Ft'
11.Borehole diameter.2.2 5" 146.F6 brivolon%veliq -in addition to sending.the form to the addrm in
24dabue..also-s'a-b—fi—fit—a-copy of this fbitti within,30-dais-of completion of iviJ11
12.W;Ckj'0tjStMCtj0jj Metljod:DRIVEN
(i.e.au�­r,iMary, 1116
cablc�'dircd sk etc�j
P.M.410it of Water Risourccis,Uildirgrotend Tnijeetion Cantml Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 NIA Siirvicetester,Raleigh,XC 2*9436
13a.Yield(glikii) 'ATM10 d cif test: 2k.F61'water'Supple&'[a Lee'tran'Wells:
Also submit one COPY of this.f6ir# srithiu 30.doysof com0letion of
13b.Disintection type: Amount:' well construction to the counly h6lih department of the coiiqv where
OftstrIlMd,
Wale FormG%Nr-t NMIL Carolina Deparimerri.of Eavircitumm artVintoW Resources-Dlivb-lon otr FtMQLO=- f(evised August 2013