GW1-2021-06867_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) Fur Intern;il Use Only: Print F orm
1.Well Contractor Information: 2
Tm" I (L� 1 14 RATER 701YES
Well Contractor Name tRtOM TO DFSCRIP'rION
330-7 3� fL ft bvn mr
ft ft-
w
NC Well Contractor C'erutication Numb r
n 1 {� ( 15.OUTER CASING for math-essed!!ells)OR LINER if applicable)
Ervironyiew ft 0901 Aq 4- r ybi'y ,JA CNInPS 'ob1 ft TOR THICKNESS M4TERIAL
fit. n.
Company Name _
y Q 1ti.LNiNER CASING ORTUBING eothermateloval-too
2.Well Construction Permit#:WAk c3t^11 111S i P*/Coc 71,4_I FROM TO ritum-rEu: TmcbgN;ss rtnTE]HAL
List all applicable well constnrction permus li.e.1,7[:,t'ounn..titute,Variance,etc.) 34 (t O rt '� in. �.�� a{0 L�.r,,,
3.Well Use(check well use): fl fL in. rY`
--1
Water Su Well: 17.SCREEN
PPIy' SL PROM Vo DL4.1f}TER AT SIZE THICKNESS M4TERLIL
Agricultural ®MunicipaVPuhltc: a{9 tt• 34 ft. Z in. O.o) Sc lim pvc-
Geothermal(licating/Cooling Supply) [3Residential Water Supply(single) ft. ft. in
industnal/Commerc:ia) E)Residential Water Supply(shared) f!t GROUT
Irr] ation FROM TO MA IIAULL _ E'%1PLkCEHENT%I£I'HOD&LMOLT"1'
No Water Supply Well: 3 2 ft. 3p ft. }'3em D iNke 30 �o uR
Monitoring 13Recovrn' ft. ft.
Injection Well:
fit fl_
Aquifer Recharge ®Groundwater Remediation _...
19.SAND/GF:AVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To 11ATt3t41L EMPIACFTFErrr METHOD
AquiferTcst ®StormwatcrDrainage Hg ft. -jZ ft. s* 2 rAeo Pe L
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) D'I'raccr 20.DRILLING LOG attach additional sheets If mcmq)
ha
Geothermal(Heating/Cooling Return)) Other(explain under#21 Remarks) }Rorl TO DESCRUMONtutor, [iw,seW—k type,Vai.un%etc)C fit tt• �• '!'
4.Date Well(s)Completed: Well ID# TrAW .. I tt —
i f
Sa.Well location: ft ft.
CaYIA $te war'_VWA
Facility/0wnerName i•acdity�phcable) fit' fit'
Call�ttp Stewwc� Imo. C1ro�rlcr '�, VVC fl __ f�. - --- 1
Physical Address,City.and Lip fl. ft. ve\\
-
County' Parcel identification No (PIN) PC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --------- --•---------•- ------���dt --�--
(if well field one ladiong is sutfictent) 22.Certification:
Nv
6.Is(are)the well(s)OPermanent or Temporary Signature oi'C'eitilicd Well Contractor Date
Hr signing lhis,lorm,I hereby cerli:that the well(s)was,(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 1 iA\'C,4(.'b2(-.0100 or l5A.NCAC:02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well constmciton iriformation and explain the nature oflhe copy of this rec'rrd has been provided to the well owner.
repair under;Q]remarks section or on the back q(this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sonic You may use the back of this page to provide additional well site details or well
construction,only I GW-}pis needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessan'.
drilled: ON G _ 1 SUBMITTAL LNSTRL'(.-I'IONS
9.Total well depth below land surface: 1 {ft) 24a. For Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths ifdlj(erenr lexaneple-3'&206'and-'4t100'1 constructor to the following:
10.Static water level below top of casing: _(ft.) Dirnsion of Water Resources,Information Processing Unit,
/fwater level is above rasing,ruse"-"q 1617]Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: (J (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
il above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rl Sn construction to the following:
(i.e_auger,rotary,cable,direct Push,etc.)
Division of Rater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636!Hail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Rater Supply& Iniection:Wells: In addition to sending the form to
the address(e-.) above, also submit o'tic copy of this form within 30 days of
13L Disinfection type: Amount: completion of well construction to the couniN :hCalth department of the county
where consinicted.
i
Fort GW-I North(arobna f)cpartnieni of Fnviruiunental Qualit) Do,vaou of Water Resources Renscd 2-22-201 b

i
+,ESP
April 16,2021
NCDEQ Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh,NC 27699-1617
Reference: FORMS GW-1 &GW-30
NCDEQ MONITORING WELL CONSTRUCTION PERMIT#WM0301111
Camp Stewart Road Site (TAX PIN# 11109204)
Charlotte,North Carolina
ESP Project No. E6-GP56.601
To Whom it May Concern:
As required by "Permit for the Construction of a Monitoring Well" # WM0301111 provided by
the NCDEQ Division of Water Resources Mooresville Regional Office to Pulte Home Company
LLC on March 15, 2021, ESP, on behalf of Pulte Home Company LLC, is pleased to present well
construction and abandonment records (Forms GW-1 and GW-30) associated with the temporary
monitoring well installed on the subject site located along Camp Stewart Road in Charlotte.
Mecklenburg County,North Carolina. The temporary monitoring well was installed as part of Pulte
Home Company LLC's pre-purchase assessment/Limited Site Assessment of a leaking underground
storage tank at the subject property.
One temporary monitoring well (TMW-1) was installed on March 30, 2021, and subsequently
abandoned on April 1, 2021, by Environmental Drilling & Probing Services, Inc. (EDPS)
(Certification No. 3307). Completed and signed NCDEQ Forms GW-1 and GW-30 for TMW-1
are attached.
ESP Associates,Inc.
P.O.Box 7030 - Charlotte,NC 28241
1.800.960.7317 NC:704.583.4949,fax [phone] • SC:803.802.2440,fax [phone]
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www.espassociates.com
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Forms GW-1&GW-30 for Monitoring Well Construction Permit#WM0301111 ESP Project No. E6-GP56.601
Camp Stewart Road Site April 16, 2021
If you should have any questions,please do not hesitate to contact me at(863) 802-2440.
Sincerely,
ESP Associates,Inc.
A,a' .
Nora A.Zirps,PE,RSM
Project Manager
License No. 023838
cc: Mr.Fred Matrulli,Pulte Home Company LLC(via email)
Attachments
Forms GW-1 and GW-30
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