GW1-2021-07990_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Inievnal useONt,Y:
nis:fonn an be Used forsingle of nudtiple Wells
1.Well Contractor information:
IL WA•IE ZONVS
Brian Ewing FROM TO 1 D. .'RIPt'IOR
tYdl Cotdtacwt Name R n
4240 S
NC Well Conumor Cenifiewion Number -15,OUTER CASING Ofterorah a sed wv9 OA LWER firaAk
034 (t.
O TTA►rFTf�R TRTCA'NFSS MATERIAL
SAEDACCO Inc 4 n. 2.250 'rim. NA STEEL
C'onwalyNant SI'NG�ORTURIN eolhemtttteseAaeo
FROMO T)IA�iF.THR TRICIC.titt.4S' MAMRIAL
2.Welt Constra cOnn Permit t1: n. in,
List all applirahlr wrll penwils lit.Conran.Starr.Variamrr.Ir%e:kn rrr.) r
3.Well use(chock well*,%c):Water SupplyWett: DIAMETER ST SIrF T1110CMMiSS MATPRiAL
❑AgAcu tural ❑Municipatl/public A 1.250 in. ..004 NA STEEL
aGeothemtal(Eleating/Cooling SuMly) 011esidential Water Supply(single) iL )n
01ndustrilllfConmtercial DResidential Water Suppt)•(shared) 1L GROUT
FROM TO MATER . EATPLACSM);NT MEMOD A AMFUR
❑Irriantion n. (L
Non-Water Supply Well: ft. A.
IMMonitoring oRccomly
Injection Well: (L
OAgoifcr Recharge ❑Gmundwater Remedinfion 10.S D ELPACK table
❑Aquifer$torngc and Recovery ❑Salinity°Barrier n, A.
MATF,RK1 RMPIACF,ti:NT 1Tn n
❑Aquifer To ❑Stomm'ater Dminagc R. fL
❑EWctimentat Technolog ❑Subsidtncc Cantmi FROM
75f
MG G atlacM addTtlmist ebMa3f acccssa
❑Geodtennal(Closed Loop) ❑ mcff TO DPSCRttmON a►br 6atwmt a yoAlhucR ere.1
❑ eodiennal(Heatiti oil Retum) ❑Other( in under 421Remiks) 25 JL FILL SILT AND SAND
48 n. SILT WST PWR
a.Date Well(s)Completed: 9-20-21 Wdi l])#GW-11A
n.
5a.Well Location: n n
Former Charlotte Army Missile Plant A. (L
FactlitylOwner Nome Facility 110(if appliesle)
R. tL
1824 Statesville Avenue, Charlotte, NC, 28206 I' I
Physical Address City.and Zip YL REM
Mecklenburg WATER SAMPLE W/SP-22
>s
C40m), Parcel ldemifrat)onNo.(PIN) I w,eR*ff1eHI
ft.Latitude and Longitude in degrecs/mimttes/scconds or decimal degrees. 2L Certification:
(1f a ll Wit,mot I*Ions is sisintiatd)
N W 1
Brian Ewi.n. 10/13/202
5ignatar�ofctrtUkd Well Conoatwr g.. Date ,.
6.Is(are)the well(&): ❑Permanent or zTemporany Ah signing this farm,1 hereby rrrrify thru the mY1l(s)Mas(MYr!)4y asiturred in mcoh ante
m-irh 1 SA NCAC rl?C.Ol ptl err 15A NC-AC 02C,O200 n ell Comsln*Mcnt Standards arrd char o
7.Is this a repair to an etustft well: ❑Yes or IX-No copy t f thin rrrnMJSnr been prmLlr•ti to the tail Owner.
If A h tx a repair.fill ma Amvim Kell eoasrrucvirm lnf tmmrkun mad e%rlaln the rtorure of rite
repair under Ali rew wrh-Areaav or ran the bark of this farm. 23.Site diagram or additional well detWt%.
You may use the batik of this page to provide additional hell site details or ivell
8.Number of hells instructed: 1 construction de lEs. YOU am also attach aM6011al pages if necessaw.
For mulrlple tojeerkm tN mrai-warrr jW.tdy wells ONLY a trh the same tonsrrnrtlaar,cost rem
submit mr form. SUBMt7TAL INSTIICTIONS
9.Total e•ell depth helots laud surfacer 38 (II.) 2da. kr All Well Submit this form within 30 days of completion of well
For ma(lriple wells list ell t(epAs lfdiffrrenr(erawtptr-3@t2M.'aad 2@ 10r) construction to the following:
10.Static water level below top ofrasing: (t,) Division of Water Resauittesc Information Pmeessing-Unit.
if water level is ahm".casing,use '>" 161711tatl Scmiec Center,Ratellidi,NC 276"4617
11,Borehole diameter 2.25° (in,) 21b.For inkWito ft ONLY: to addition to sending the form to the address in
24a above. also submil a copy of this fame within 34 days of completion of well
12.Well constl twfl0n metbod: DPT construction to the follmNing:
(i.e.auger rorajy.cable„died push e1c.)
Dh•t.Rlon of Water Re°sonrecs.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY. 1636 Na Service Center,Raleigh.NC 27699 1636
13&Yidd(gpm) Method of tcstr 24c.For Water Su ltr&In oction Welts:
Also subntil one cosy,of this foal within 30 dais of completion of
13b.Dlsinfbetion tyro:. Amount: well construction to the county health dcM#want of the county whcre
constructed. k
Form GNt-1 Nonb Camilm Dgtadntem of Emimnmrcnr and Natural Resoumes—Division of Rrater Resouoe9 Revised Atgust 2013