GW1--05396_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD ForIRkmalUse NLY-
Thii;form can be used for single or multi*k actls
1.Well Contractor information:
II.WATER ZONES
John Eiseman ji FROM TO DOCRiITION
Welt Contractor Nam h. h.
ft. ft.
4439
NC Well Contractor Certification Number 3-$.O4IT11R CASING(for sasid•gawfdwt"OR WtLR Of a F,R.sab$e)
FROM TO DIAMETER THICKNEsr MkTTRir1
SAEDACCO ft. h. is
Compton Name 16.(NNIR(AS'U 4.G ORTVOlfkimotheraml elrat4 __ r_..
FROM 79 DIAMETER THICKNESS MATERIkI
2.Well Construction Permit 0: 50001357 0 ft. 23 ft. 2.25 io- NA Steel
Lira all applicable errll prmtits fir.forty.Awe,Variance,blialicrt rn•.t ► —
h. ft. in-
s.Wei Lac(cheek rid'ass): *Matti Water Supply Wen: YROM TO DIAMETER NI.OT517i: I TttlfKRrss ,, MATERIAI.
OAgrkuitut>tl IDMimicipaliPubiiC 23 ft. 27 ft. 1.25 ia• }004 NA Stainless;Stee
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
I
QinduutiaVCotnrtteniati Dkcsidentiai Water Supply{sllatad! Its.GROITT -----I\T
FRQtt TO MATERIAL E1tFIACFMENT METHOD d AMOUNT '
❑lmt►on h. ft.
Non-Water Supply Well:
O. ft.
®Monitoring DRecoyriy ----
injection Well: h. h'
DAgaitcr Recharge (3Ctroundw:ttcr Renncdiation It.SANIKattAVEL PACK(if ty-j+tlicnakt #4
pAgtnifcr Stott a and Recoyr ClSalitaity Barrier FROM Tt) SI ATI RI%I. �I•NPI.((iMO VI Nit I MOD
8 f5' ft. ft.
Cl Aquifer Test DStommwatcr Drainage rt. ft.
O xpentncrual Technology °Subsidence Contra!
3t pRII LING LOG(attach adelldlanai ihr•Hs if srctttan t
OGeothcmial(Closed Loop) DTracet FROM - TO DESI•RIPTtoN iavbr-I,Ardna•......t1 nor R IN rx.rrx n wa•,ah I
❑Geothermal fileatinj,+Cooling Return) (]Other(explain under 02 t Remait s) It. h.
IL ft.
4.Date WcIl(t)Completed: 8-12-24 Well IdDPT-4
n. rt.
Ss.Well Location: h. ft. ''• t't,'; ,...
Clariant Mt. Holly East Facility f4 ft. % �'r.... /) 11
SEP 6 9 2024
Fx.till%01tncrName Facility 1Dk(ifapplieahk) ft �
1170 Mt. Holly Rd., Charlotte, NC, 28214 ft. ft.
Phtsical Aoldnss.C its,and Zip w- _ .....:.. .•-. w.dirt_,_ . ,. -
21.R!Ft"RK
Mecklenburg Grab sample via SP-22 screen point sampler
Cation Parcel Ide*DflcatlonNo.(PIN) I
5b.Latitude and using talk in degrccs/minutes.'secnnds or decimal degrees: 22.Ccrtiticntion:
Or welt field,ono 1aeloat(Is sufficient)
N µ• '' t„ 8/29/2024
Sie-Ware of-,,,-.7.-`d. • tr..!!"..1+ -- t :c
6.Is(art)the well(ti): JPennanent or so Temporary "� _ , ✓sa � +
!h ri4—.4.gals Jbi;d cure-,‘"rfv?r Cr -. ..v r a rtYl vi ntrnrcrni in acr•onosity
ieik 154 NCAC 02C '1<, Y .t" ,:...IC.0200 Weil Co+i re vi a Slo kfort a and Ara a
7.Is tiik a impair to an existing Nett: MYes or ZINo ropr of rut eranr+f furs beta provided to eke evil(wit:
Il this b a apple,fill o'a,lowers well aosaurt«'tints ilfferrnan011 trod tuplo n at*gore of the
repair wfFrr S2l r+naarta eertiew or or,t/tr baton of this fowl 23.Site diagr.tn or additional well details:
You may we the bock of this page to provide additional well site details or well
IL Number of wells aoostrueted: 1 commie-non details. You(nay also attach additional pages if necessary.
For awe *isJeeut(.n or aim ewer vrvpir wells ONLY etdt the ratan+eosrst randon,toe ern
SUMO'ane fortes. SUBMITTAL INSTUCTIONS
9.Total well depth below hod surface 27 (fr.) 24a. For Ail Wells: Submit this font within 30 drays of co,> tion of wen
For eudriple wells list ell*Mel if different(e-rmnpk-3w700'and V*Ifir) construction to the foltoning-
1t1.Static water level below Itsp of cam: (ft.) Division of Water Resources.Information Processing Unit,
tf,rrtrer level is above rtlsiRft<px.4." 1617 Mail Service Center.Raleigh.NC 2 699-1617
I L Borehole diameter:2.2 5" ths.) 24b.for fn(eetloe wens ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of conviction of well
11.Well construction method: OPT consaniction to the following.
(it.surer telary.cabk.drat post, etc t
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLI': 1636 Mali Strike Center.Raleigh,NC 27699-1636
13a Yield lttpenI__ Method of flat: �.For Water Supply fat Injection Welts:
Also submit one copy of this form within .(t days of completion of
13b.Disinfection type _ Amount: well construction to the county- health department of the county whose
constructed.
Form(1W-I Montt Carolue Dcpanntem of Ern minnow and Natural Resomccs-f:thmion of Water Resources Revised A[gu t 7O11