GW1-2023-02079_Well Construction - GW1_20230307

WELL.CONSTRUCTION RECORD For G!icrmlUscONLY:
T11g rorin oan lac used Cat sifigle or tnuliipk wins
1.Well Contractor Infortnatiort:
'.ra:.wa-eertzoNFs
Brian Ewing FttUSI 7(1 nFSf'RtPTl1Y\
W01 Co tilydClor Nimo ft. %
4240—B
NCWdlContnlclorCCrliftcationNU31bCr t&OUTER Ct151NGifur''F6111�vwrt40! 'ORLiNER'fita" ticabkl
FROM I To T TInCK1r-5 NTAIT.RtAI.
SAEDACCO Inc 0 it. 6 iL 1" 11n. SCH-40 PVC
(onslr;my f ante -16;INNHR.CASING'OR=777BING.c•i-,t 6 Ld'dak-d4ou ►'
FROM 70 DLMUTER I THICtm>irss 1rATERtAL
2.Well 6n-tr'pct16n PCj nrit 4, 70003216 R. ft, 11L
Lt,i till iq.piNrabh?v.d!penwfrr(i_g.Coimn'.:Slrm,lrariaiwe,1jaYd&.gr1r..J O, rL to
3.wcli iise(cheek Well use); t7:srltr�h
-- Fnnu To orAatvTrR sr,0TSj7; arAr TillCKY11s -
♦�aterSnpply WWell: RRrar,
CJr1gliculnrral i 1Mtuiicipat4N.iUlic 6 rt. 16 ft, 1" 1D' 010 SCH-40~ � PVC
❑Cicothemial(lieatimy'Cooi1Q Supply) ®Residentiai Water Suppl}•(single) ft' fL itr,
❑industriallContoterciA ❑Residential IKirer.Supph•(slsttrd) ;t8 GROUT: .-
FROM 70. bfATER1AL ENrPLACE\IF-NT.NWUIOD.t,kIIOUNT
131ni Rion
Noti-Watcr Supply►`tat:
6ahlonilnrinG pRccol'cty' - ft. ft.
Inject tort Wcll: rt. rt
QARnifcrltcciiarge to 4mumaalcritcul diation -is:SANDIGMILVELPACK'Jifut'dkabtey
F'RQII TO ,1L171tRIAL F:SIPLACI]1rEVT H!"rHou
❑Aquifcr.Stdnlgc and Rccoti ti' ❑5alinity Barr... 4 R. 16 ft. FILTER SAND # 2
❑Arliiifer Test ❑5l6nm'1-Itci Drninnge
rL. tL
❑EV- erinlcuml TCchnotoe,,g 175tttisulencc C'onlrul
2n.DRUXINGIOG'616ch eddltWm'gl sheets if rteemarl•r
130wifignual(ClosedLoop) OTmOr FROM' To DEseRIPTtU�tc�ar.u,rorrc.�,x+u4'nnkn n .�xt
❑Geodtettnal(Hear ntVCoolillg Retuju) ❑0her(expL•iin minerA21 Retuar,ks) 0 • .fL 5 ft, FILL SILT AND SAND
5 ft.r 15 fL MOIST TO WET SILT/ CLAY
4.Date IW I(s)Conipleled: 2-10-23 Well➢D#TMW-5
15 ft. 16 iL WET SILTY SAND
<s�
Space Craft f4 IL �i�% _.�ti,@i"rtlm'
Facility.'O"rName Facilh,i IDk('ifappli abW R. ft.
525 Parkwood Ave.,, Charlotte, NC; 28206 MAR a
ft. ft.
Phvsisal Addr'ss City.and Zip :21.REM1IAPXS
Mecklenbur 08304212 `BENTONITE SEAL 1 TO 4'
t:cmnl}• 1�rcC]Icl'_illiCtc;lduu Ntr:(P4ti)
eb,i.aritudc anil I cingitudain t1 n Wtninut01ssconds at'dccimul cfc�nccs: 27 Certiticntiun:
(itttell Bold.Uih+hvbl)ug is'stdi k10 '
• a
It ►► 2/14/202
_ Bri 3
Sigmtui JCcaiGed Nell Caauxtar -� Date -
6.is(ttrl')We'IYeII(y};nPenuailent of zTemlloran' kv SArmli C litiY�ofm.,l 1tCfYh/'CCfftfv fl)rlt the tl'Cll(!'J NUX(kL"'/YJ Cif,g'1raClerl lrr;rcc'onlmiGr
16irh ls•t XCAC 02r,ol aq dr hs't•'k-w 0k.020D Well Coustrq:nnn SrdWdrds mid ilxrr,r
7.ba this a reitaic to ad esistta;;welk ❑Ye't or ®Nt► rec6n1 lies'been pfovided ro My sill miner.
rf Ih(s.lti a reivik.fill cnvi kcouvl wed emifi 71+.'l jej liffprmajiml doW t:lptghl r1e_mrive of'rhe -
repairmidrr A?l'r�mar11!'rruian ar ivr nc�brut of thix fnrnr 23:Site diAgrain Or additional well details:
You na),use tb'e back-of this Im�[o pro�'ideudditionat hell site dru:fils.or rtiell
8.11nluberof wells cotuttucted: 1 eousuuctiun details. You inay idso attach additiou4 P'Lkes if liecessan•.
For raakiple lydecihm or non-nearer tnpply n'efls ONLY n'irh rbe.sntrrg ca*rrsrtiirteorr,pear temn
submiroiie form. SUBMITTAL INSTUCTiONS
9.Tot:it ivell depth below land stiri'acei 16 C(t,j 244L t'trr Ail Wells: Snbndi this form within 31J.days of eomptctiott`of,Yell
For rnahlple Welfs list rdl depths eonsinection to the foiloning:
10.Statie hater IeYel below top of em-ing: (ft,) Divisitin nfWpter Resnurccs,Information Prueessing Unit,
iflrelive levdls tihore cos(nl;,hse"+" 1617 hlait.Ser vice Center,RAlei;h,NC'27659461.7
li,Bprchotc diamckm 2.25" Cin.) 24h.Far tliicglinn Wcth ONLY: in addiiion to setiding the fomi to tit-address in
24aabove. also subinit a copy of'this fonn within 30'days'of completion of Wdl
12.,well constmetion Metllod,DRIVEN cousiiuetion to the foliorving!:
(i.e.auger.idary',cable,direct ptisl�erc.}
.Rivision of Water Riyout'ccs,Vrider�onud ittjcrtiotl Control Ptngram,
FOR WATER SUPPLY WELLS ONLY- 1636 MA Service Center,Rulelgh,VC 276"-1636
l3;n Yicltl(gjim) Nlcclrotf of test' 2dC.For Water SaUTA .tic 1!iCqw'iydh.
Also submit one eiipy of this fortis within'30.doy$gfconipletioit.of
13h.Disinfection lype; Amount: =11.cohmnictioru.to the County licalth dcpartinetit of the county Whirs
ccinstrtictcd. �
� i
Fanu G%V-t \onh C;rolilta Utip¢nn>crq.uf Eqt imttnxrlr artd Nu[aral RCsourecs-Diviilon of IYalcr R att Rcviscd AugttvA2013.