GW1-2021-07992_Well Construction - GW1_20211122

WELL CONSTRUCTION:RECORD For internal use ONLY:
'fins ions can be owd fa shigle or mul iple wells
1.Weil Contiltetor Information:
14.WATER IONES
Brian Ewing FROM TO I osSIC-R!P111014
gall Coratracicr Norm
4240 B
NC Well C0fltr torCenifrcalionxumba 15.OUTER CASING rrrar seem Yn OR R Ml
livable
FROM To DiAMEM THWKNFSi MATERTAI,
SAEDACCO Inc 0 (LI 39 rL 2.25" ia. NA STEEL
CofWaty 1,12me FROM TO G OR"R}BIKNf� tksed4Npj
R TtnCKNUSS MAiIEtuAL
2.Well Construction Permit f1: ft I a. its
list all applicable wrdl pemritx 0x.Caunty,Starr,Variamr.Merl cn etc.) ft. ft.
3.Well Use(check well use).
Water Supply Well: FROM TU DiAMMR sr Sirs, nuC-KNMs MP,lAI.
OAgrictlltural a municipal/Public 39 ft. 43 fi- 1.25" fa, .004 NA STEEL
OGeothetmal(Heatin&C.6olirtQ Supply) DResidential Water Supply(single) tt ti fa
01ndustrial/Commercial ORcsidentjal Water Supply(sallied) 1&�
FROM I To D1AT1?WAI. LNUILACEMITNT KM OD&AM011W
owpation ft. tL
Non-Water Supply Well: ft
®Monitorin DReco,.c
to"on well: �+. �-
DAquifcrRccharge 00toundmrntcr Rcmediation 1fii3ANt1 E r
❑Aquifer Storage and Reco-m iy ❑Salinity)3arricr IM M R. ft. MATPRUL, I RMPI nm"T Mt rpon
❑Aquifer Tetd DStolmmIler Dminagc
ft. tt.
DEVerimrnksl Technology 0Sttbsidericc Catxml 10..DRUAANG WG s1lkMadditimraf sifsreccasa
❑Geothenual(Closed Leap) DTmcer mom TO DESCIRWrION(cobs. arMe rr aw,cu n tRte Net
DGeollienttal(Heati -ooti Return) DOther( ain under 021 Rentaft) 0 A. 10 h. FILL SILT AND SAND
25 h. 43 ft. SILT WET PWR
4.Date Well(s)Completed: 10-4-21 WdI M#(W-21 h. fL
50,Well Location: 1L fL
Former Charlotte Army Missile Plant h. fL
facilit)r+0%=Name Facility ID#(if Wp)icable) �,
h. tL
1824 Statesville Avenue, Charlotte, NC, 28206 (L hNOV 2 2 2921
Physical Address,Cin.and Zip 2L RIeM
Mecklenburg WATER SAMPLE 14/SP-22 DV'J¢iSECTION
Cantu. Parent Idetairi=ionNo,(PIN) i 11,7TIUMATIOM PROCESSING VMI
Sh.latitude-and Longitude in degree tralautes1wouds or decimal degrew. 22.Certification:
(if mell field,one worc Is srdt)ckta)
N W Rrian Ew �.i.ng._ 10/13/2021��a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): EVermanent or B1Temporary ey signing this form.l hrreby e'rrtio,that the aril.t)wvt Nriv l 4%twinre w in awortionrx
with 15A NCAC 02C.010)or 15A KCAL(PC.0200 lirell Contrrnt-tfwr Standards and AV
7.Is this a repair to an exisdog well: Meg or MNo ropy of this nvord has hero prarlded to the aril fsuwr.
1f ibis it a repair,fill out kaown will ronstr wyinn hrforowrlon and exphrin the Harare of rhr
repair emderd21 rmorl r m1imr or on the ba l ofthis form. 23.Site diatom or additionai well.detaits:
You may use the back of this pap to provide additional well site detaiis or well
8.Number of wells constirwed: 1 construction details. You may also attach additional pages if uccessafy
For mnitlple 10n'rlon or arwr-wmer mpplrr wells ONLY%4M the some cotrsrrartfxte Yom can
sxbmitroteform. SU INSTUC-TIONS
9.Total well depth below land surfece: 43 ((1,) 24s. Fbr All Wells: Submit this;folio within 30 days of completion of well
For ma#tpk keilt lis oa*pths ffdorrni oxaaysre-.t@20fi'mid 2@Ifff) construction to the folGming:
10.Static water lestl below top of casinir (1t.) Division of Water Resources,Information Promsing chit.
tf xvtlerlet'd If Ahore rosin$.ate"4" 1617 Mall Scmice Ckinter,Rsteiglt,NC 27699-1617
11.Borehole diameter:2.25" (im1) 24b.Fgr injection Wells ONLY: In addition to sending the form to the address in
24s above. also submit a copy of this form within 30 days of completion of uOt
12.Well construction method: DPT construction to the foltouing:
(ie.miger.ratan•,cable,dine-push ex.)
Division of Water Rcsalrres.Underground InJecflon Control Program.
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh.N. C 27699-1636
13a.Yidd(gpm) Method of tests 24c,For Water Snpplr&Injection Wells:
Also submit one copy of this forum within 30 days of completion of
13b D£tinfe4tinn hp� Amrwnt well construction to the county' tar fth dcpartnxyll of the colmh where
constructed.
Fonn G1V-t North Carolina lkpttunem of£mironsucts and Natural Resources-Dhislon of Ulster R(sotrtrs Raised Attgug 201.1