GW1-2021-06866_Well Construction - GW1_20210429

4/6/2021 1:25 PM FROM: Fax TO: 19198076498 PAGE: 001 OF 002
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only
1.Well Contractor Information:
Daniel Summers .......... .:::::::::::::::::::::::::::::::::::::::::::::::
I4 WATER 2ONES.t:... ::>. .::.........:................:.. ::::,.:,.
... :.:..... ......... ...
FROM TO DESCRIPTION
Well Contractor Name 14 ft. 29 ft
2579-A
n. rt.
NC Well Contractor Certification Number ...
-
IS.OUTER CASING'for`mr[tl='t4SEd 1Ytl1 'OR LIPiEit llCadre
Carolina Soil Investigations, LLC FROM TO DIAMETER t THICKNESS MATERIAL
company Name 0 ft 14 ft 2 In' sCh 40 pVC
I6.3NNTR.CASINGOR-T6BIIVG eother•msl ctosert-l" : .:�� '_� '<_
2.Well Construction Permit#: SI P#70002769 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(r.e.UIC,County,Slate,Variance,etc.) ft ft In:
3.Well Use(check well use): ft ft In.
.....
IT.S"GREEN .... ....
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Q Agricultural [ Municipal/Public 14 ft 29 ft 2 In 010 soh 40 pvC
Q Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft ft in
El Industrial/Commercial Q Residential Water Supply(shared)
4> GROUT ......
Irrigation
-- ©Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n 5 ft Portland mix&Pour
Monitoring Q Recovery
5 ft 12 ft bentonite tremie
Injection Well: ft ft
Aquifer Recharge GroundwaterRemediation
3 i►N1)iCRAv pAC1C,lE' Weble ...
:: ... .............. r
. Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 12 ft- 29 ft 10/30 silica sand tremle
Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) i Trace
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne solurock tvDp grain size,etc
0 ft. 29 ft brown silt loam/brown silty /saprolite
4.Date Well(s)Completed:03-09-21 Well ID-4 MW-10 ft M
5a.Well Location: ft ft
City of Charlotte Aviation Dept. ft ft 0
Facility/Owner Name Facility ID#(ifappliwble) ft ft \] A
5020 Hangar Rd Charlotte, NC ft. ft.
Physical Address,City,and Zip ft. ft. �, A
Meck C�
21 RR.MARir$ .... .. ...
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/sewnds or decimal degrees:
(Swell field,one lat/loeg is sufficient) 27. er ca on:
35.20762 N -80.94739 W 03-09-2021
6.Is(are)the well(s):E]Permanent or Temporary signature ofcertised Well cofFactor Date
7.Is this a repair to an existing well Q Yes Or NO By signing this form,I hereby certify Oat the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.02oo well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarb section or on the back ofthis form.
23.Site diagram or additional welldetIhits:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled: 1
SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: 29 ([t.) '
For multiple wells list all depths if&fferent(ecample-3(200'and 2@100) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water lever below top of casing: 26 ([t) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" g
8„ M) 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
24b.For Injection Wells:In addition to sending the form to the address in 24a
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division or Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injectlon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the'county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division ofwater Resources Revised6.6.2018
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