GW1--04619_Well Construction - GW1_20240809

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
Thts form Can b:,Reel for singk or rnultipk uelle
I.Well Contractor Information:
14.WA111!EOM
Tyler Brown PROM I
TO e1AfRIP1KrN
Well C'otanlcirn Name R. ft,
4625A ft, ft.
NC Welt Contractor Ceti ificatbn Numberj 15.OUTER CASING floe meMnoaed eels)OR LINER of aetrlratk)
!IRON ' To DIAMETER TKKE'cFSS MRTt1tAl.
SAEDACCO 0 fl. , 20 n. 1 is. SCH-40 PVC
Cowan)Nang i to.INNER CASIN OR SING r�E�altlaad•IMeI
FROM i TO MAaRTRR 11110ENESS M.\T111111�
2,Well Coaatnaction Permit d: 70003214 ft. ] fit, te.
hir all applies abk urlf permits tie.County.State.Yariaace.IT$a1W4 et.-.i
R..-IIJ R. i�wi
.
3.Well Use(check well nsei: 17.SCREEN
W'aterSupply Well: !ROM To DIAMETER t1OTNI77 I TRKTfhkSS _, MATERIAL
°Agricultural I_IMunicipa4Public 20 R. 25 ft. 1 is. `_O10 SCH-40 PVC
❑Geothermal 1Healing,Cooling Supplyt I IResidennal Water Supply(single) R. ft OIL
0Industria1iComntcrcial I(Residential Water Supply(shared) le.GROUT
FROM TO , MATFRUI. 7 EMPLACEMENT METHOD&ANOINT
❑bngatton R. ft. -�
Non-Water Supply Well:
ft. n.
H Llmntonne ❑Recovery , _
Injection Wi41: R. fl.
LIAquikrRecharge ❑GroundwaterReincdiatlon us.tiANDKY.AVELPA('KfirappYcaNe1
FROM 10 St STRCISI. i 1-NIPI.tt FMI\T MFYtn)tt
°Aquifer Storage and Recovery ❑Salinity-Barrier R, n.!
°Aquifer Test ❑Stortms:ucr Drainage
ft, ft,
❑E<penmcntal Technology ❑5nhsidcrcc('(Rant 20,DRILLING WG launch adWitional sheet,if seminars'
❑Geothemwl(Closed Loop t ❑Tracer )Tema to ows uirrom 14.311•4-,kardeers,voilharkt.nr.ur...n•.sr,.
❑Geothettmrl(HeatingCoolingReturn) °OuterIe\platn under 1121Rettwtl,�I ft.
ft. ft.
4.Date Walks Completed: 7-19-24 Welt iDiB-4
5a.Well Location: n. AUG a, 9 2024
n.
Perry's Market D. (1.
Neill'',thuxrvAlm: Facility!Motif applicable+ 11. lu. lr, ialit..t,.'.l i'--so '-,g J.r,..
Da/1..s 3 i_..:r
6727 Wilgrove Mint Hill Rd., Mint Hill, NC, 28227 n 11.
Pinsl:al Mdress.fit).and Zip ' 21,RIM.RKo
Mecklenburg I
(a,inh Nreet Identification No (MI
1
5h.Latitude and Innoittrde in degtue(uduRtealsmrnds or decimal degrees:
(if well Arid,me Iar:i,,,rg rs stdl,,eres10 22.Certification:
N W' .. 1, --z__'- 7/19/2024
Signattni!'of nified Well Contractor Date
6.Is tare)the wants) :Verminous or X lcntporan
Bs signing tads fume.1►awake certify thug the Reheat wwr turret cof rtrtn•red in wean/awe"
with l SA NCAC 02C.01(1 or 1 SA NCAC 02C.0200 Weil Crutafna-tirur Swnrfards said that a
7.Is this a repair to an tsisti.H well: JYes or KNo r,:y,.•1 else, „rd has hero eto,'rdrd r,the,.ell owner.
If tfrit u a repair.fill out known well(mamma,rnforaarrirw axrl r.p4tut the motet'of the
repair under Ill remarks.ruction or an the bark of Mix furor. 23.site d iai,ram or additional well details:
\,',is 111c,, is..ilk back of Otis page to provide additional well site details or well
8.Number of wells constructed: 1 col stnt.uon details. You ma'also attach additional pages if tecessan.
For Mulhhplr raieer/441.-s nw,•.r.,,.r,1151r,a,-1,O!%f.1 wort Ow tawe raeseawftea.w*,RIP
Naibmir one h•rrn. S l'L RMITTAL INSTUCTION S
9.Total well depth below lard surface: 25 (11.1 24a. For AR Wells: Sttbmt this form wttlnn 10 days of completion of well
For want*,.rl'.l,,.r..i1,h•pth,if Afferent fe.rampfr•3@200'and:Or WWI construction to the following-
10.Static water kid below top of ca llrg: (ff.1 Division of Water Resources,Information Processing I nit.
Omar,level u abrtvr,using.axe•"♦" 1617 Marl Strs'iet Center,Raleigh,NC 27699-1617
I I.Borehole diameter:2.25" (in.) 24b.for[niceties Weib ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this faint is Felon 110 days of completion of well
I!,Well instruction seedbed:DPT cottsttuction to the(Mowing.
,1 ::11C:r.nun.cable.direct push.etc I
Di%bion of Water Resources.l!ndcrgnfaad Injection Control Program.
FOR WATER SITPL\'WELLS ONLY: 1636 Maul Sers ice Crater.Raleigh,NC 27699-1636
2k.For Hater Supply S.Injection Wells:
13a.'i kid igloo Method of test: _
Also submit one cops of this fora within .o dass of completion of
13b_Disinfection„ile: Amount: well consmutw county
n to the coty hcahh department of the county where
constructed
Fonn GW-t Nona Catalina DCtiennent of Ens Roc II.1,,..ea\.norri Resources-Division of Water Resat:es Res iced August 2013