GW1--01774_Well Construction - GW1_20240320

. WELL CONSTRUCTION RECORD For blurs]Use ONLY
The form can be Rscd for sink or moltipk ucfls
I.Wi91 Contractor information:
U.WATYR ZONtS
Stefan Smith FROM TO DESCRIPTION
\Vela(ortri t,r Kano ft. n.
3576A ft, ft.
NC Welt Cosuractor Can ifnaiton Number 16,(M)TtR CASING ffir oul-cared was)OR USER fit apphcrhk)
FROM TO DI METER THICKNESS NI VITRIkl
SAEDACCO 0 ft. 10 n. 1 is. SCH-40 PVC
Compost,Nance ,1Iw llN1FR CON TI$1NG)jptttiteraaid elsw44.op1
PROM TQ DL1.METER THICKNESS MATLAR!.
2.Well Construction Permit ii: 70003186 n. n. hi.
List#a apprkaor well prmuti lie:Canty.State,Variruur.Neat";ens) ,
ft. n. is.
3.WRt use(shack well lase): .1 .. - K _.—... ._.._
Water Supply Wen: PROM TO DIAMETER SLOT S173 ; Tltt('K`ONK i MATERIAL
0Agrictdtutai OMunicipaVPubtic 10 IL20 ft. 1 IL 010 1SCH-40 1 PVC PRE-P K
t7Geothermal(Heating/Cooling Supply) fResidentiai Water Supply(single) n' h' in j
Dlndustrial/Conuiterrial °Residential Water Supply(stand) ` CRO11T
PROM TO MATER(Al. 1ZMPL CEME\T METHOD R AMOUNT
❑bngstion it. ft.
Non-Water Supply Well:
rt. n.
ItMonitori O m Recrry IL H.
la)ration Well:
f3Aquifer Recharge °Groundwater Ren(e(lauion t#. V8 PA (if r Flieaibkl
PROM TQ MaTkKtvd, i FSIPI.'at Iv1r\T Nil Tnnn
°Aquifer Storage and Recovery °Salinity Harrier 8 ft. 20 ft. Filter Sand #2
O Aquifer Test DStonnwater Drainage —,
n. n.
DExpetitncntal Technology CISubsidcncc Control
NI.nail 1.IK(:LOG(astacb addltinnut sheets if occr sri)
OGeothermal(Closed Loop) OTrace: F'RUy iO DESC'RIPrnr\i..rbr,b,rdnr...awl m,at.!LEK.,r.dn..ir,ck I
OGeotheal 4eating(Cooling Return) OOther iexplain under If/I Remarks'I 0 Alt* 20 ft. Silt
mi
ft. ft.
4,Date Wd l(s)Completed: 2-19-24 Wen Mg Tm -3
Sa.Well Location: n. n. r. (ti,r L.,.i +i Lew 1...
200 East 7th Street Owner LLC ft. IL MAN 9 o 2074
Facility/OwnerName Facility IMO(if applicable) ft. ft.
324 N. College St. , Charlotte, NC, 28202 ft, ft. !n' -- �"
Mikal.Adder:�Cit..and Z' �, ,_..... _ _.....,.........._.�.
21.RCniARKS
Mecklenburg 08002401 Bentonite seal from 6-8'
County ty Parcel Idcabfitatb*No.(PIN)
Sb.Latitude and Longitude in dettrecs/minutesttecnnds or decimal digress: 22.(crtifkatian-
(ifucll rod.Dtx !Along i,sidti::x:io)
35.228047 N 80.838796 W *Y! T 4.41- 2/29/2024
Stgnn of CeIlificd Wcll Cono actor 1).r.:
6.la(ere)thews l(Sk 13Permanent or IcTemparary 9v signing ibis form 1 berths nrrr(fy that the adX(s)writ fsan),omtruetrd in at'tbrikince
with I SA NCAC 02C.0)tlr)or)5A NCAC 02C,0200 Weil Cmnsrrw rice Staralards and that o
7.Is this a r'eptlr ta act existing well: ClVes or No (nisi of due rerr.n1 has her%proorkd ro the serf!nwtwr
If this 1t ri'cont.,fill ow buten aril)owl/notion information a hs plant the notate of the
repair nadir a_1"iriaorkc*Mimi Of on the beet of AIr/arst. 23.Site diagram or additional well details:
You may use the back of this page to pros ide additional well site details or well
8.Nuasber of dwells eoustrncted• 1 conatnrctton details. You may also attach additional pages if necessary.
For a.islr)pir L jeeslt n or aai-w ter ugtph'wells ONLY with the raids eapspxtctfo t,: non
subunit one Jaen.. SU$MIfp j,INSTUC'f1ONS
9.Tot&well depth below laud surface: 29 mi.) 24a. for AR Wells: Submit this fonts within 30 duos of completion of well
t Mt.hipte x ill s list al depths if diffirrent(example,3f1200`mod 2*Mr) construction to the following:
lit.Static ti ater level below tap of (ft,) Dh binn of Water Resources,Information Processing Unit._
1617 Mail Service Center.Raleigh.NC 27699-1617
I1.Borcbak diameter:2.25" (it.) 24b.Far Injection Weill ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well amstractioa method: DPT ConstrtietiOrn to the following:
tic.auger many.cable.dihCt path.etc.)
Division of Water Resources.Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Sets Pee Center.Raleigh,NC 27699-1636
13a Yield(gpm) �lctholsl of teat: 24e.For Water Supply &injection Wills:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection hpe: Amount: 'Well construction to the county health department of the courts wheio
-'- constructed.
Form OW-1 1sane,Camhna Avon moo of Ens teonmcnt and Marine Res+oumcs-b)siswn of Water Rnautcc Revised August t 2019