GW1--04637_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For Internal Ilse ONLY:
This form can be used fox singk or multiple wells
1.Well Controller Information:
M.WATER ZONES
Robert Miller PROM to DES('RIP1MIN
W'ctl Cnturrctor Namc ft. ft,
2675 n. ft,
NC Well Contractor Certification Number 15.OVTER CASING(for taehi•cnrd weer)OR LINER(if Neable)
MOM TO DTI SIFTER THICKNESS M,4TTRIAt
SAF.DACCO 0 ft. 31 ft. 2.25" is. Steel
Company Name ILINNER CASING OR T URING(Bealhermal clued-1wrM
ROM TO _ DE4MFTER TRKT,:MESS MATERIAL
2.Well Conetrectinn Penult N: 50000079 R. ft. ie. ,
List all appli,able n rot rrnrr..'li C.('.,u.n .Su:.,.Iar,ae r frlediar1 rlr.1 ..
f1. n, ie.
3.Wdl Use(check well wort: ' 17.SCREEN
Water supply Well: YWM O TO D1.1M,..TER SLOT stet THICKNRSs I MATSRI1t.
°Agricumlral °Mimicipal;Piklk
31 0. 35 ft• 1.25" ilk .010 ! Stainless Stee
()Geothermal(Heating4 oohing Supplyi °Residential Water Supply(single) rt. rt iw
0Industrial,tomnteteial °Residential Water Supply.(shared l ta.
FROMGROUT TO MATERIAL IMPEACEMENT METRO°l AMOUNT
❑Imgatinn R. ft,
Nan-Water Supply Well:
R. n.
01Monnonne ❑Recover}• __
injection Weil: n. ft.
❑Aquifer Recharge °Groundwater Rcnlcdiation Iv,.ANO:(.RAVEL PACK id atp,Ikahkl
VHOt1 10 rl1T►-Kt11. 10411.14-1,MIN1 ME7110t1
°Aquifer Storage and Recovery. °Salinity Barer fa, ft,
❑Aquifer Test °Stortnwatcr Drainage
ft. i It,
❑Expenniental Technology- ❑Stthsidence Comm'
2o,DRILLING U)G Ignacio additional sbeeti if nccsc an I
❑Geothcmtil(Closed Luopt ❑Tracer mow I t0 lWM RtrT1osi hove,hitrdur..•V.tr'I,ML t.pc,-.T M".t,r.do-I
❑Geothermal(Heatinu'C'ooling Return ❑Othet Ie.plam under a21 Remedial R. fL
ID R. ft ,. 1,., i f E_
4.Date Well(s1 Completed: 7/18/24 well ARCD-13 r.. '4.-! i1 .
n. n.
Se.Well Location: ft. ft. AUG nj S 7014
Shell Oil Products, US R. n a_-•,
Fa c,lii w net Nutt' Faciles iDs(if appl►:abl 1
f. ft. DfR`t:::1, d
101 W. Woodlawn Rd., Charlotte, NC, 28217 R. ft.
Physical Addters-City.and Zip H.REMARKS —
Mecklenburg 16903203 Grab water sample collected via SP-22
t...,lit n Parcel Identification No INN
SI).Latitude and longitude in degiv slmitntteslseenndsnr decimal tlegttcit 22.CertTicatuta:
Itf well field,Dar I:u�lutg ta,tdllektur
n myy 7/26/2024
signior of.. s::.,::fi..;-_'' .:c .A.A . Date
6.is tare)Ibe!nibs): ❑Pcrrnanent or SITetnpuran g)•signing this floss,.i hereby terrify that the walics!was(were)sstmrmrted Si,atrotdaacr
with 15,4 NCAC 021C.0100 or 15A/.CAC 02C•0200 Well Caetractioa Standards and that a
7.Is this n rlwlr Or ma existing well: ❑Yes or ®No ropy of this neon,has lwrn provided to the well owner,
if this it 0 repair,fit out known well comma-non information and explain the nature of the
repair tinder 121 remarks.sretea,or net the hark of this franc 23.Site diagram or additional well details:
You may use the bacl,of this paw to pros ode additional well site details or well
8.Number of wells constructed: 1 constmctiun details. You mar also attach additional pages if necessary.
hit multiple utjrrNent<e n.vi-,1,1 r,,apple wells ONLY with the mew constrartti. .trip can
,etbmir one form. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: 35 ((i,) 24a. For All Wells: Satinet this form within i(I days of completion of well
For mihlplr t.root)i.t,tjl Jrpaht(t tittle.,CM M•.tutttp(r•- 34*'IAT u,ttl Nth Pei!. contlnictlnn to the following•
lit.Static water lent below top of cas1ng (ft.l Dis mien of Water Resources,lafermatiea Processing Unit.
.. . ,. ,. . . 1617 Mad Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter:2.25" Oa.) 24b,Fur luk'stioa jirklis ONLY: In addition to sending the form to the addtess in
24a abose. also submit a cops of this form within 30 days of completion of well
12.Well culistrnction method: DPT consltw ttun to the following.
tic.saga.tout).cable.direct push etc-I
Dhisiun of Water Resourtcs.Uadcrgrueed lajedlea Control Program.
FOR WATER SUPPLY WELLS ONLY: I 636 Mail Sere-it,r Center.Raleigh.NC 27699-1636
IJa Yield lawn) Alrtlutd ofn sic 'Sc.For lh'aler',uppls &laje tioa Wclh:
Also submit one cops of this Mem w Mon 30 days of completion of
lib.Disinfcctinu type: . t: well construction to the counts health dcpnnnrent of the coma%where
constructed
Fern GW-I Noah Camino Deportment of Ens itomrtl and Natural Rcsotecce-Distlon of Water Resources Res ised August 2011