GW1-2023-02614_Well Construction - GW1_20230410

• WELL•CONSTRUCTION'RECORD
ea • /51.3UFo Interal Us DNLY
This form cult Wind fr single or tmoltpk wells \ I
I.Weli.Contritetor Information: 1 • . .
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't4LWATBRZONES- ; ' '
Brian Ewing FROM TO DESCRIPTION
WcIl CoOlmcliirNanIC . . ft. 0. I '
424 0-B ,
NC Well Contractor Cert ifientien Thurber 15...OUTER'CASING'ffilratOlIkased:Wensi OR LINEICHfuli titablet,.. ..
FROM I TO DIAMETER TRICKINESS MATERIAL •
SAEDACCO Inc . - 0 ft. I 5 ft,• -2" I I in. SCH-4 0 . PVC
Company Manic. -IS,ANNER(CASING ORTUBING;(enirtheitnal cklied-luaRr - --- -
FROM TO - DIAMETER TITICKNESS• NIATERLAL
,
-2.Welt CORgrutenn Porn*it; 70002 933 R. ft. I I in.
MO itU c.ggicabfr weftpeireirs.(i,,i.panty.-Skim,'Variamer,flea*.0.7.1-
• n.. rt. , 1 El.
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3.'Well Use'(eltcc Ikwell DSc): 17:SCREEN • - . • .
' .
• Water Supply Well: - FROM 10 _. ntAmETER St.OtS17. I TnICKNESS I MATERIAL
ricultitrat
5 ft. 15 R. 2" • Ft .010 SCH-9 0 Pvc
ClAg - EiMnitiCipal)ThablIC
.t.' -
• Met:dermal(1-leatingXooti Pa Supply) ElResidentiat W R. f to,ater Supply(single) 1
ClTudustriabtonuncrciril OReslelentiaaet, uppy(sared) -
• l Wt Slh FOONI v.TO. 7 MATERLAL -EMPLACEMENT NIE1111001 sc AMOUNT •
• El kriootion . 0 'R. 3 •ft, PORTLAND Tremie
• • Nati-Waiter SupplyWell: • - •
E .hlonitoring 10 Recoyety __, ., _ . .
Injection Welt: - ft. IL
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- . 13Aiptifcr Recharge . • Otionnilwalcr Rcincdiation - ..IT.cSANDIGIEAVELTACKlit tiptillealitel ,
• • • - - ROM no • 711,trioarm. •• .1iN1PI-AeTMeNT union
. : ClAnniferStaingc and Itecm'ery .1:Salinity Harriet' 4 rt.: 15 ft, FILTER SAND # 2 • . • •
13Mulfcr Test ; EISIOiniwatee Onliefrige .
f.. f.t.. . .
otirtint.entai TceilinolM• IZISol:Sidcoce'COntreil• .
20.ORME:1Na ILOGIuttacli;additioital Sheets'if;mei:Snit-NI' •
00,entliono:6 cicisetl Loup) • lThacer I FROM - TO . DESCRIFTIONnvbr.turritnemsiaelock woc.:*--gn Oise,tic.1 - .
EIGeothennat ttleatitutiCooline Return EltItherplain nailer.421 Retuarks) 0 ;ft, 5 .14 FILL SILT AND SAND
5 it, 10 ft. MOIST TO WET SILT/ CLAY
4.Date Welf(s)conipleted: 3-14-23 .. '•Oireji QD#M41-DT-0 2
' 10 'ft. 15 rt. SILT CLAY MOIST TO WET
5 .Well Location: .ft. ft. !. •A-.1.::
•Atrium Health ' It. ft,
Facflitffhvivri!liutte Fkility 117i4(lfupp1k(able.) • , • '—AR tt, R-71—• 0--le 2
1130 Blythe Blvd., Charlotte, NC, 28203 . . ft. • ft.• iffic..ri•-i::3;1.7..;1 PIT,--,-—-- Ur• -
„ •
. . Physical AddreSs,City...and iri '• .2 LitEmARKs, . ' . . . .. :,.....u,..::',..q....-,.; • ' • '•
Mecklenburg 15302327 BENTONITE SEAL 3 TO 4'
Comity . Parcel liknliftitIon No;(PIN) . •
. 5ii...it.ittint4e ani1-1.anglitedc,in degreeliminutesisecOnds cir deleintal•clegrecn ;22:Certification:. '
(if u ell tick!,one Intim%isfaittleienn
N 'Pr' Brian Ewin g 3/21/2023
Sigruturief Certified Well Contactor ; - - Dale
6.Is(are)thoveil0: X1Penitattent .or Effemporary By sis:ning tar Afirr.,I Acre.'")cenify that Iht!we'll's)mu.614.4e)anivimelext ht.ficarrdcnc-e
with.15.1NCAC 02C.0100 or I.SA NCAC NC.;AM Mil Coritivcrion Standapis and Aar ti ,
7.Ls th.br.-a repair fu an ekistiogycll;' Erecs or 331M) -rcipr cif Mir ityrini/th, f.sx,,provided rari1e or!!(limier.
• If riVsli 0 tepaik,Jilt 4Nry kr:oi.te4 waf CONSMdardikPrillalkol 074 ti.vp(4h1 illivoutrare of the
iipair rtiAt 02 t tivntuks'.serilan or Lei the barkofthis form: 23:Site tilingnitwor additional.ws41 details:
You may use the back of this page to.Movide.additional well Site details:or Welt
8.1Strittherof Wells eoustnteted: 1 construction details. You may also attach additional pages if necessary.
For AirmIrdWr injecriOn or tran-muer supply wells ONLY with thi'taiiieg.earrstrodriva,y(41 coo • ..
saOluit one f6rtn. • • S UBRIITTA I,INSTUCTIONS
9.1intil welt depth betow laud stirfare: • 15 • (ft.) .24a. Fur All Wells: Submit this form within 311 days of criOuptcriatiof well
For lnoltiplei...,eiti list iell depths if dili.reur(own fp fe-3€'2i3,9'and.2@ ply) construction to the following:
;
lit.Static water level below tap of casing: (a.)' Division of Water ReSriurces,InfurrnatignPrutessing MID,
If mire(11,64 is iabore disitig,ilse"4-" 1617 MailSei-viert Center,Raleigh,NC 27699-16 t7
El.Borehole diameter:8•25" r(in..) 246.For TOleellort Well ONLY: In addition to.sending the form to the address in
24.1'abeke,also submit a cot* of this form within 30 days-of completion of well
I 2..Well coustmetion method:BORED construction to the foilowing2;
• • (i.e.:Angel.,letasy.cabl.e;diicct inish..ctc:}
• Distiou of Wntor Resources,Underground Injection Control PrOgram,
. FOR WATER SUPPLY WELLS ONLVi - 1636 hind Service Center,.Raleigh,NC 27699-1636
24e.For Water Supply;&Injection Wells:
3.3a,Yield Wm) NreChad of rest: •Also• submit one copy of this:fan Within 30:days of completion of
E31u.D wctl.construction to the county health department.of the county where-
isinfection type: _ Amount: _
constmeted.
Form GW-I Nook Carokna Department of Euvirolunnu and Natural Resources-Division of Water Rmoircm Revised August 2.013
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