GW1-2021-07996_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For lnteradi Use ONLY:
Tlds form can be awd(or single or mmllip'k walls
1.Well Contractor Information:
:t4,t?1rAtl3R 7AN&�-
Brian Ewing FR M TO DFCSCRlrMoN
WC11 Gaol wot Narm h. A.
4240 B
NC Well Co maorCetlifrcationNambcr 15.OUTER CASING•(ffbfbr i}RLINER limb
i!!d
TO DIAMETER Tl M-NESS MATERIAL
SAEDACCO Inc 20 h. 2.25° i in. NA STEEL
CWnpan•Namt I&INNIZR CASING OR TURING . ilic�isai t eiase4
FROM TO DIAMETER THWI N'ESS MATERIAL
2.Well E`onstruction Permit P h. tt, t++
fr"tt all gWUrnble writ penwits lire.County.$We.Wirlawe,11#r n etc'.) h. h.
3.Well Use(check:well usc): i7.SC,It)CRN
Water Suppi�•Weil: FROM TO pinnirrER St S171s. TincacVM-- MATi iAl.
Oftdcultarul OMunicipatIlublic 20 ft. 24 f6 1.25" lm 004 NA 3TSEL
C]Geothettttal(HeatiDgfCooling Suppi}) C1Resintial Water Suppl}(single) h' fL In
(31ndusaiallCommcrcial DResidential Water Supple}•(shared) 8(iROiTP
FROM TO MATERIAL ER[PL&CKMEXT 3Hf_'tr10D A AMOIr'%
Olaf• tion ft. It.
Non-Water Supply Well:
mMonitorin Oktccovc h. IL
Injection o. IL
OAqulferRccharge MmundnwterRemcdiation t .S W,it71Ri1VEL1�A- . kiiible
❑Aquifer Storage and Reco,.ery OSalinity Barrier FR M Ma RtAr; tzMrLA�ssmtrsT MrTr1 fl
h, h.
❑Aquifer Try ❑Stommmer 0minage
OExpcnatental Technology OSobsidemc Control h rL
O.DR1L1.1R'G 0 dlsfiti aildlllorialn #'.
OGeotberniul(Closed Loop) OTtacer FROM 170 DFSCRIMnN r►br.bardncs+.w-Wr cls ntsro.erc.
OCeotlmemmal(Fleetil ..2oli. Return) 00ther(explifin under#21 Reta&) 0 ft. 10 fL FILL SILT AND SAND
10 f6 24 % SILT WET PWR
3.Date Wetl(s)Completed: 10-2-21 Wdi jD#GW-12
tL fl.
5a.Well Location: ft. It.
Former Charlotte Army Missile Plant n. tL
Focili 4ow cr Nam Facilih kDK(if licabtc)
A. ft.
1824 Statesville Avenue, Charlotte, NC, 28206 ft. tG NOV
Physics[Address.City-and Zip 21.RRh1ARIt5
Mecklenburg WATER SAMPLE W/SP-16 YdT C 1V
k1M.W.44.1051
Caton• PAMd Ide►difie.1tion No,(PIN)
5h.Latitude and Longitude in degnx0mkmsteslscrnnds or decimal dam: 22.Certification:
(ir W ell field,otro talong is xr►fficlerd)
N W Bria,n�..Ewing,. 10/13/2021
signatmR4 Ufcenifred Well contractor Date
6.iS(art)the wdl(s): aPermanent Or Elfemporary By signing►hit four,f,hereby eerilfy Ow the wdks)was(sowr)mms-t ucted in mcorditnree
isith i to NCAC 02C.01tk_)or!VA NCAC il:C.0200 Bell Constrwrlan Standards and that a
7.Is this a repair to an existing well: E3Ycc or mNn rnpr afrith nvani ha twee prm•ided to the aril rtw'ner•
tfthis it a repair,free ant mouse well rmwnAr m lKfomvihm xW explain the tin mrr of dw
reMir uaderd2l rmwrka.retirron or cs"the Karl of thin farm. 23.She diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of welts constructed: 1 construction details. You mad'also aflach additional pages if necessary.
For nmUlf*f*rdon or woi-wsarer supply welts O1VLV 44th the some ronsowdon.yan rats C iBbitTTA .IltiSR 11"T[ORiR
submit me forty,. _
9.Total well depot below land surface: 24 (tt.) 24a. For Al!Wells: Submit this form within 30 days of oompletion of well
For tnwltiple wells tin all depots tf dfQerrm ferample-30200'and 2fe I(W) construction to(he following,
10.Static water level below top of caslop (f.) Division of Water Resnun:es.information Pnmeessing(snit.
if wntrr level is share crrdng,use"+" 1617 Mail Service Center.RsltiRh,NC 21699.2617
11.Borehole diameter 2.25° 01L) 24b.Dr I1111idgn VS-b ONLY:` In addition to sending the form to the addf=in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well 4construction mabod: DPT construction in the following:
(.o,auga.rowrg,cable.dirm punk etc.)
Division of«`wise Resource' Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mal)Service Center.Raleigh.NC 27649-1636
13a.Vidd(gpm) Method of test: 24c.For Water Sappkc&inJoetkin WCOS:
Also submit one cafe of this form Within 30 days ofcompletion of
13h.Disltrfcetion h'p�. Amount- well constmctian to the county health deparnew of the county where
conSCmctod. 1
Fonn G W-1 Noah Camilm D4 minwm of Eavirurmrnt and Nanoul Resouroes—Division of Water Resoures Revised August 2011