GW1--05166_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fosin can lx used for atngk or nrulttpk uctis
1.Weil Contractor information:
14.WAYS.*ZON1113
Rich Lemire MOM TO OEM'OPTION
WO!(a,)a Oacf.r NAM ft. ft.
2593A ft. ft.
NC Welt Catr eetor CcRifdtioa Nsn ci ,,,A. [NG r rtruisi.tmsed urns)OR LINER Of applicable)
PROM TO } DI-AMFTFR TIIICK\r\ti i MATFRI AI
SAEDACCO ft, ft. j M. }
Convoy Name 16 1 A 1NG OR •1 .,s.t i *bermes'chows`ieta
FROM TO D1A.ME1TR TNK K'AESS MATER!AI
2,Well Constrscllon remit 1: WM0301368 m " 0 ft. 20' rt. 1" 1n SCH-40 PVC
Liza eft emlicaubfc writ pane is i.r.County,Same.Variascr.Ittertioa et..a •-•«---.
rt. rt. itr:
3.Well Use(cheek well use): 17.,t Rci n
Water SupplyWel: ERQM I TQ ' DIAMETER MAO hi tut(t<\I,, AiATIRIsM.
20' ft. 30' It. 1" ia. .010 SCH-40 PVC
3Agr cultural C Munilcipai/Pttblic _._______
pGeothcimal(Heatif,<giCootin8 Supply) °Residential Water S ,(single) I'- IL ia.
0hadustr sitCotnnaekcial ` CJResidetuial Water Supply(shared) -1.GROUT
/Rost TO MATERIAL i EMPLACEMENT METTIOD A AMOUNT
Oltngstion 16' ft. 18' ft. BENTONITE POURED
Noa'.Water Supply Well:,
ft. ft.
ODMonilorinn ❑Recovery
Injection Well: IL h•
°Aquifer Recharge LX.imundwater Remmediation try.-_.' e' ''vacmC ij )
°Aquifer Storage andReeovvty 1 inth Harrier " MATERIAL Port t(IAik\1\1k moo$al
18 ft. 30 ft. SAND #2
E1AquiferTest [ StoTmwaterDlainagc
It. ft.
Al xperimental Tc'.r:httolo ' OSublEideuce Can*Tnl 1
20.DRILLING LOG runic((atdditimisl duets d'icrman)
QGeothermal(Closed Loop) °Tracer : rRo%s 10 ' DrscRII'Tl0\.tvbr,I.ilrsim,,,...I...si.h pc.grain oft',esi.a
DGeolbeitisal Oleating/Cool nit Retool) DOttier(explain under 021 Rerniaik6) 0 It. 30' ft. RED SILTY CLAY
ft. ft.
4.Date Wt: (f)Completed: 8-7-2024 Wen mDSTP-1 . .
fL ft.
Ss Well Location: ft. n. ' .
.
Jason Ernst ft. it. AUG J 0E624
Facil Oss;ter Mune Foci*,IDS Of evol k)
H. N,
3100 N. Sharon Amity Rd., CHARLOTTE, NC, 28205 h, R.
Physical Address.City,and Zip „,#r1 ItCMARkfi _- ,__..�. , .__. _ .., __ .
MECKLENBURG 10301137 BENTONITE FROM 16' TO 18' .
Course Parcel tbentifieetasrINo,fPIN)
5b.Lade and Lomas*In 41101,211/111bMitelibleeonds or decimal degrees: 22.t'ertificatiun:
Of wetfCid,01M tied OM it 5effriCiCM)
. _ t � '
N W Ci =-'i✓Iv..r+,,... 8/9/2024
of .Weil Connictef Date
6.Is(are)the well(a): t Permanent or laTtmporaly By sigmas Oris dam, I hrrrM Eeefs•that(tear tansy!was terry)eon bea'trd s,:;.tr¢rdemtcn
wok i:Fd NCAC OW.0/0)or LTA NCAC O2C.0200 Well Commit-rim StandareIs and this a
7.Is this a repair to an existing wdl: QYe s or 11.No rape of this Word it terma prnrirted to Ai.wall revne)t
If this ii a tee*,.:flit arat.*mem wwtf rimrructteNn tatfamatkulroll eviabe:As otaimre of the
repair under 021,a.mants.se.:"iiaa or a the bare of this Prat. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.NumiHer of wells constructed: 1 cotestnect on is. You may also attach additional pages if necessary-.
For lostItipk et e-.-. ter "476 k.elf:O,NI.t ..ith th same construction S,:kit fen.
se6mi1 w fatm. SUBMT'CIAL INS7'UC.noNs
9.Total well depth below land surface: 30' (ft.) 24a. for Mt Wells: Submit this form within 30 days of completion of well
For~Meta wells list oil if dtrrrrnt keaseplt.30200'uat1120wltlff) COTtstmotion to the following:
10.Static water level below top of cashng: 21' (ft,) Div ision of Water Resources,Information Processing Unit.
tf swan level is assert easaag:am. + . 1617 Mail Service Center.Raleigh.NC 27699-1 6 1 7
II.Borehole dimmrter:8;25" tin.) 24b.For lnjtetlon weal ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 10 days of conviction of well
12.Well cDnsiractbru method: AUGER construction to the following:
tic.woo,rotary.mask.direct parley etc 1
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Maul Ser►lkt Center.Raleigh,NC 276994636
13*.Yield(gpst<) Method of test:
24c For Water Suppis&ielection Weds:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,,,.., .- - Amount• _„..,,,.. __-„ -,. well construction to the county health department of the county whew
constructed.
form 0W-t Montt Catoitna thxaartntcnt of Ern)roninctn arid Naru al Resources-Division of Water Remoras Res not Ataguu2011