GW1--04638_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD ForrnernaluseONLv:
This form can be iocd for sink or'milt ing%idle
1.Well Contractor Information:
l&WA ROMS
Robert Miller PROM TO DEM111P1IOV
Well(•nntrcinr Natty n' ft'
ft, ft.
2675
NC **cif Contnrtor l cnifk tt n hum lrrr 1S.OUTER CASING(for melii•cased OCB!)OR LINER id aprhrahkt_
FROM TO Di4MrTFR TT(R'KOFN.0 NI lT1Rtkl
SAF.DA000 0 h. 31 d. 2.25" is. Steel
Compton NAM 16.INNER CASING OR TUBING(girolhersat cliisd-loop)
-know ' TO T D1ttr'rrR t tt(K'tSS M•►T!RI\t
2,Well Cuaransction Peewit lt: 50000079 n. 1 a. in.
Lk!al.rppiicabtr welt permits tie.County.Shoe.Vonance.h section rt-.) ---
. R. 1 ft, w.
3.Well Ler(check well ti,e): 17.S('REEN -Warr Supply Well: ratOM TO DIAMETER tit.nt.trr : rout Kai.. Ny1FRIAI.
❑Agricultural ❑MunicipalrPublic 31 35 ti 1.25" M .010 Stainless Stea
( In. I
❑Geothcmtal(Neating.Cooling Supply) ❑Residentwl Water Supple'(single) R' R' I
❑htdustrialContmcreial ❑Residcntal Water Supply(shared/ 1&GR00T
(rROM F 70 yl sit ktAL EMPLACEMENT METHOD&AMOL1VT
Ohnpation h. it.
-
Non-Water Supply Well: ----!
It. ft.
Q1Momtonne ORceovcry .
injection Welt: ft. ft
❑Aquifer Recharge DGroundisatcr Renscdialion 19.SAND.t:RAVt L PACK 4if t4Kd:cahkl •
❑Aquifer Storage and Rctimnr ❑Salinity Barrier rnt►yn rO MATT-IOU. t mIN.At'rMrVT mFt11pD
R, ft.
❑Aquifer Test OSiommatcr Drainage
rt. It.
❑!grenmcnlal Tpchnobgv ❑Siisidet>Lc Cotatal 20.DRILLING LOG(attach additional sheets if eccessar.i 1
OGeothennal(Closed Loops OTtacet room I TO , tw'c,nrtiox Univ.h,rdwr..,...e..,..t.t.pt.Ir.e.,x,dr.i
OGeothermal(HeaiintpCooling Remit CJOtlscr(explain under 92I Remittal ff• ff. .... _. f ..
h. ft. i r. �.. 7. 1l " �.;
4.Date Well(s1 Completed: 7/18/24 Well ID11 RCD-12
ft. ft. Atli .J 5 2024
Si.Well Location: rt. ft. '
Shell Oil Products, US fth ft. irr•.'v:r:k,t:r. A-rr JyN‘.`1 tietli
FacilaylOwner Na me Facility Me(if applicabkl —-
ft. —.
101 W. Woodlawn Rd., Charlotte, NC, 28217 ft. ft.
PIn s*.;d Aa$drrss.Cih.and Zip 21.REMARKS
Mecklenburg 16903203 . Grab water sample collected via SP-22
--(-am I. Y - -- Parcel ldcmrrK-,ll,1 No MN)
r
5b. l.Mint dc and Longitude in deerrestminutesrseennds or decimal degrees: 22.Ckrtiticafioa:
(IJ u cl:Odd me Lis long If sIdlic>tnl
N R` J,([`'�// e7 7/26/2024
6,le(are)thy ss ell(.1: Permanent or 71JTemporary Dr dgnMg riots farm.I hereby eerret dine the wrll(tl war(broil comenrcted in accordance
with I S,4 NCAC 02C.01110 or 15A NCAC 02C.11200 Well Co,wrnctian Skatidords and that a
7.Is this a repair to an existing well: _l`es or X No t'tspy of this nvrond has been pnmid.A to the urn owner.
If OW Is a repsur,fill on;*Rtrww welt c'onana-non)4,rIneaon,tad eVptatii rh5 Naar(of the
repair ruder 121 remarks.mteon or on the bark of this farm. 23.Site diagram or additional vi ell details:
You may use the back of this page to pro.ide additional well site details or well
8.Number of weii tieastructe l: 1 construction details. You may also attach additional pages if necessary.
For muhrltk mi,,rk+w o N,NI•..<,rer opals well:ONLY not the it ma~Awake too con
submit one fair. Sl IDMITTAL 1NSTUCT1ONS
9.Total well depth helm land surface 35 (t1.) 24a. For All Wells(: Submit this fomi ss nhm MI days of contpktion of well
For m..hipt.•1.eth tut ere!deal:,,!.hfives trxasnpf-30200'molt?@'10+) construction to the following•
It/.Static water keel below tap of maim (11.1 Dih ision of Water Resources,information Processing Unit,
1f water keel:,,d•..,r,data,,err••4." 1617 Mail Service('enter,Raleigh,NC 276'99-1617
II.Borehole diameter:2.25" (IL) 24h. For lu action Weib ONLY: in addition to sending the fomi to the address in
24aabose. also submit a copy of this loon within :M0 days of completion of well
12.Well construction method: DPT constriction to the folios%ing
rte.super.tours.cabk.direct push etc 1
Division of Water Rt.se.rccss,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Rakish.NC 27699-1636
13a Yield((rr►mt ‘h rh,.d,if n lest:
21c.For Water Suppls ,N.Injection Wclh:
- Also submit one .opt of this font nithrn 30 dales of completion of
136.Disinfection ape: Amuunc well construction to the count health department of the edam where
—_-_ Con noted
Form GW-t iienh Camhtra Dcpanneiu of Environment and Natural Resources-Unaton of W.tlas Resotrc i Rcs dud At•gtat*ill?