GW1--04635_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For Internal Use ONI.A
This form Can he nyd for sini:k•or mi.tiipk yens
I.W'dl Contractor Information:
I I4.WATERZONhtS
Tyler Brown ►ROM TO I [WsM•piPTION
Will('nnrirpx tank
R, ft,
ft. ft.
4625A
NC Well Contractor Certification Nenbri IS.OUT[R CASING Nor meltieastd wells)OR LINER of Walk)
IitOM TO maser FR MR'10Tv. NI TT41t1
SAEDACCO 0 R. 20 i. 1 ie. SCH-40 PVC
(_,uup:ut)Nana: 16.INNER CASING OR TUNING( thermal dipMdeet) _.. -..-1
MOM TO MAMETER _ TSICKNFcc MAT[R►AL
2.W'elt Construction Permit N: 70003214 ft, ft, is.
Liu an apph:nble Wrlf prnnue Are.C,,ynfV Stoehr,Vigilance.Injection r,r.i R. R. ilt.
3.Well I;se(check will owl: 17.SC11E8ff
Water Supply.Well: totem TO RIAMRTInt MAIM/S. TNi('KptYs NI tt I RI%I.
❑Agncultural OMutricipal:Ptrbhc 20 R. 25 ft. 1 010 SCH-40 PVC
OGeother mal(Heating,Coolittg Stlppl.) OResidennial Water Supply(singlet ft. ft. iR
OIndustrial'Comniercial OResidcnttal Water Supply ItGWDT
Ipph(shoed) FROM TO MAT SItIAI. envLACT IO NT ME11100&AMOUNT
❑Irrigation rt. ft.
Non-Water Supply Well: f, ft
Kklomtonne ❑Rceot'crs
Injection Well: R. ft.
_ 1
❑Aquifer Recharge ❑(imrundnatcr Rcnicdiation lit SANIM RAVEL PACK(M applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier !ROM TO MAtaeun. FMM.tr TurNT Mrrann
R. ft,
❑Aquifer Test ❑Stormw:Her Drainage
R. ft,
❑ENpcnnicetal Tcchnotoes ❑Sabsidcnce('onml
20,DR11.1 ING LOG iar(acii addtlioeal ehr>ti4 if acce.san l
❑Geothennal(Closed Loop t ❑Tracer ',HMI ' TO PFM RIPTnrN I to(rr,hard own,,alert-lurk tart.tram"or.dt.l
❑Geothetinal i leauiie/(oiling Rollout ❑Odter(c"plain under N2I Remarks) `---_tt. rt.
ft. ft. '
W'd R
4.Date 1(a)Completed: 7-19-24 Well IDaB-3 Pc `.
• ..-r •r`.; rJjD
Si.Well Location:
rt. h,
Parry's Market rt. ft. AUG V 8 2024
Factbn Orretc Name Facility IDO(if applicabkl (I. R.T Ifr.`i:T Jrai; P. A'r.r.u.4 1��
r'4,
6727 Wilgrove Mint Hill Rd., Mint Sill, NC, 28227 r.- ft. . r. D'At•a 3L•fli
Physical Addicss,Cin.and Zip 21.RCM tRKs
Mecklenburg
Corry pared Id.mdr sing No !PIN!
Sh.Latitude sad laeiiMde iR de pycea/mhwtca/aeconds or decimal degrees: 22.('crrification:
Of well field.one bit/long Is wfRckrl .
K W ` 7/19/2024
Si ,of Cenificd Wen Commis Detc
to.1s tare)the wcllt.l: 'Pennanest or X"iem(prran gi.silk this form,f kerin•cerrifi•duo thr emits,tau turret e5Jarrnnted in acrordmrtr.
with 1501 NC.4C 02C.0100 or 15A NCAC 02C.0200 Well Conansrtmn Skoakirds elnd'hal a
7.Is this a repair to an esistieg well: Lilies or 1i No ,.•r,of thi,err-,.nl has Is-rrt i.raviderl to the vr1,owner,
if this u a repair.fill tw1*anew Weil,anon.,iosr,rh.rns,rooi seer erpkwt rht•,rrrrrr of the
repair war,021 rrmurl,era r.m K iv,the hark,.(this form 23.Site diagram or additional wdl derails:
You our. use the back of this page to pros pile additional well site details or well
8.Number of wells constructed: 1 construction details. You teas also attach additional pages if necessary.
Fur malrrpir tnn•<tool,.,non-rater.tt(ytli ry lh ONEY.rtrli the MIMIC etmsreac4Ot. .„a,on
salmon tone J,..rar. S I!BMITTAL UNSTUCT1ONS
9. well depth below laud surface 25 at) 24a. Fur Ad Wells: Submit this limn ttnMu 1(I loss of completion of hell
For mahipk W1'111W ld/ATM,ifdrflrrrn,tetromple-t# 00'rout'l•Ion conatniction to the following
III.Static water Ind helms top of rasing: (ft.) Division of Water Resources,Information Processing 1 nit.
lr..a:r.,r.,4,.abort...usinf.11.• . 1617 Mail Service Center,Raleigh,NC 276994617
I I.Borehole diameter:2.25" (hit 24b.for!niceties Weib ONLY: In addition to sending the form to the address in
24aabose. also submit a cops of this form within i0 dais of completion of well
12,Well cows eetion method:DPT cotrsttUCtioo to the folios%iltg.
it c.auger.Man,cable.direct push etc I
Division of Water Resources.Underground Injection Control Program.
FOR %1 TF'R SUPPLY WELLS ONLY: 16.14 Mail Sen-Ice Critter.Raleigh.NC'27699-I636
24c.For Water Nuppls S.Injection Vieth:
13it.ti it•ll irpoil Method sliest:
Also submit one cops of this Finn militia itt dass of completion of
136.Disinfection tspe: Amount: well construction to the counts health department of the county where
constnicicd
Form GW-I Nook Caiobna Uqionnicm of Ens liowirtu and Natural Resources Dn.ssion of Wale/Roams Res red august Hit I