GW1--04829_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD For laiemsn Vat t7NLY-
This formcanbe mod f r single or multipk urns
I.Well Contractor Information:
' I1.WATER ZONES
Robert Miller FROM TO DRMCWWTIOR
',Veil Ct I-I *or N.Inw ft. ft.
2675 n. ft.
NC Well Contractor Ccrtiftcalion Number l 15,OUTER CASING(for multi-ented wr$s)OR LINCR(W so kiddy.)
t FROM TO MMAME IC TFR THICKNESS H'TTRIRI
SAEDACCO S 0 ft, 20 ft. 2.25" in. Steel
s �
('ont(run t:,nw , 16.INNER c,'-t iNG OR _ INN(teetileroiall close44eup)
FROM , TO DIAMETER TUWKNESS MATERIAL
2.Well Construction Permit 4: 70002865 ft, ft, ie.
Lire all afr,licabfr aril pertrdtr tit.County,SOW.Variance•bia041 err.) ,--•--•^- --. ». 1
ft. it. in.
3.Weil 1 N:(check wen sse): . ('7 _.
N.tterSupply Well: FROM TO (MAW Tr It I st.VT SIZE , IllicKsI:,S SI.1 FRI NI.
Ufrgricrtltolat f]lvttalticipat/Pubtic 20 B. 24 ft. 1.25" is .010 , Stainless Steel
OC,eothermal(heating Cool ng Supply) [:]Residential Water Supply(single) ft. rt. in, i
DindustriaVCommett tat t)Residential Water Supply(stlar+ed) G_FROMROUT To MATERIAL t?srPLS TttE sT MtTUou.c AMot;NT
❑Irri stion ft. W.
Non•Water Supply Well:
ft. ft.
tliktonitonnn DReco'tcty ._ _
Injection Well: fb rt.
DAquifer Recharge DGroundnater Rentediatioa lg. AS:D<ItAVt_L 1 u t:(if applicabtvt - -
i.Kom I to ' .Lt'I t WI%I 1,aNI,U I-trlN.1 NIT rHon
C]AqurfcrStorage and Ramcly ElSatinit)'Barrier ft. ft. II
•
°Aquifer Test Dn Stonwater Drainage ft, ft ----
D1 xper9nteNal Technology [)Subsidence Control Ni.nail I I.IG 1.0G(attach additional.beeft if nereatnrt 1
OGeothennal(Closed Loop) °Tracer , FRUSI i II.) DESCRIPTION.,t..nr,a;.ran.,.,..,,4umI.r,ix,won....,04 r
DGeothenttal Meatingrooliip Room) DOthet texplatn under 421 Remads) n. h' r
ft. W.
4.Date Wetl(s)Completed: 7/23/24 Well IDS GW-1 & GW-2 ...., L.. i! I.� Li)
5a.WO,Location: fr. rt.
AUG 1 4: 2n24
Rintkus ft. ft.
Facility•Ott rcr Name Faedm iDa(if apptrahki ft 4. h.........:.,,1 1, .4�::,1i..,011
Drhl.a'.4,(;,
2699 W. Sugar Creek Rd., Charlotte, NC, 28262 ft, ft,
.....l a _.... - --- ----.._.__ ___:-.._.._._....... 71alricsl A.ddloss,Cin,and Zip � 2t.RtMARKS '�,;,
Mecklenburg 04704113 Grab water sample via SP-22
Conn Parcel ldetrt t"tc Eton No (PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.('crtiftcation:
of ucll fcltl one Wiling is suftin:u«It
K W _ .» 7/,25/2024 .�....
Signature of c..• .!. ! �t.K.-__._ Doc
_
6.D(thee)thesvell(a)t t7Termrnent or SiTemporary By SIMM r tint t,>r.w.I nrreh,,r,rrf,thus thr weals)Farr(Ksrtr) n rtnterd Ie acrordwce
wolf
H 1 TANCAC O?C.O1 rx1 1 5.4 %C4C a2C.0200 Weil Cojt trurrkm Stundards bid rhos
7.La this is sepldr to an casting von: Dyes or MN() rape of this whorl ho.%;wen provided to thr$.vtl wart
qdrisis a repair;Jill ens Bono"well eonstettetista ie/vnnatike and rg4ain the N6rrtrr of the
repair Nader 121 rramtkr tertian or on the rhos*of shin/wxr: 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.Iilrarberoif weils constructed: 2 constnietion details. You may also attach additional pages if necessary.
For awiripk infection or nor)-miner wells ONLY with rfn•sorter construction wit can
submitoneform. SiTBMIITA .INSTUCI1OjS
9.Total well depth below lased surface 30 (ft,) 24a. For An Wells: Submit this form within 30 days of completion of well
For noiltrpit wells s ILO alydepth-I If different feurap!r.3s200'imi 20I00) eons,mction to the following:
10.Static water lend below tap of teasing: (ft.) Division of Water Resources,In formation unceasing l nit.
ift.oteri,.:,,above cool,ate"s" 1617 Mail Service Center.R.iteittt.N('27699-1617
11.Borehole diameter:2.25" MO 24b.For Inbetion Wegg ONI,V: In addition to sending the loon to the address in
24a above. also submit a copy of this form witlitl 30 days of completion of well
12.Well nrnst uctiun method:DPT condo fiction to the following:
._::r r.a..able.dinar pests do} Division of Water Resources.Underground Injection Control Program.
FOR W U T ER SUPPLY WELLS ONLY: 1636 Mat Service Center.Raleigh,NC 27699-1636
t 3a l field(>pm s �irrhod of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this forum within 30 days of completion of
13b.Disinfe tioo n pc Amount: consmiction to the county health department of the county where
constructed,
Form OW-1 North Carotins Dcpannt[nt of Ern-immoral wen,and Natural Rt-sotrtces-Ditrston of Water Retot>:ces Rea used Alva 2011