GW1-2021-08010_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For literml Use ONLY:
This form can be ased for single or multigie n°°ells
1.Well Contnwor information:
ta.WAIrn zoNES
Brian Ewing FROM IDFS rP11tr3\
Well Cormaerot Name R. A.
4240 B R. R.
NC'WdlCannworCcnifrcationNutibv Ii.GUM CASING or i-c**dkrtis ORUNER if SMJ;
FROM TO PTAMF,TMR; TMCKNESS MATERIAL
SAEDACCO Inc 0 R. 20 (L 2.25- it. NA STEEL
C antp un'Nanrt t6 CA51TTt;t]R_7Y)$MG t►etrw9 eleteda
FROM 70 DL%METRR 7URCILVESS MATERIAL
2.Wdl Construction Pcmit#.* (L R: �
list all applicable well permits(i.r.C'aunry.Simr,tariam %llfe:69n etc.) R. h.
3.Well Use(check well use): 1 .SCt2E1 t
Water Supply Wa., FROM 'M DIAMETER i SrAJT tn: "ICr NiF, MATMarAt.
OAgriwhural DMonicipal/Public 20 R. 24 It. 1.25- to' .004 NA STEEL
QGeothentml(Heating�Cooling Supply) Olkesidential Arater 5 R. tt. iar
Supply(single)
Dindustrialfcomntercial Oltzidential Water Supply(shared) FR.1M 1
FROM To MATFaI,u. esn�t..�cT•�+Rrwr ME�mon&w�totrvT
❑(rri tion R. R.
Non-Water Supply Well:
mmoniforin ORecotie • Q. IL
injection ell:
OAquifer Recharge OGmundwater Remcdiation t .SANDIGRAVE pA %ti tt
oAquifcr Storage and Recovety (]Salinity Barrier FROM f+tA RIAt, r?MPIA..WN Ni7H n
R. R,
OAgmfcr Tcsi oStorrrmmcr Dmirngc
OEV- crimcntal Tochnotogy ❑Subsidatce Control
r20. 1RnAANt"t.INt/ Ntattt addlilonlitsMds ifoGoothermal(Closed Loop) oTracer M TO DFSCR.tmol- abr.a.ts vowftary , fro artl
oGeothenual(Heati line Remm) othlter t aia utder a72 f Reemrl�i (L to n. FILL SILT AND SAND
R. 24 R. SILT WET PWR
4.Date Well(s)Completed-. 10-2-21 Wdlmor-W-9 IL
Sm.Well Location: R R.
Former Charlotte Army Missile Plant iL it.
FocilA Y0,vwr Nan c Facility-iDk(of applicable)
oq
1824 Statesville Avenue, Charlotte, NC, 28206 R R
Ptgskd Address.Cin.dad Zip 2G REM
Mecklenburg WATER SAMPLE W/SP-16
Cooney Parcel ldtrn r"taallo:(PIN) (a,A .a_ tril�i a�C170";r
5b.latt(tudc and Longitude in degRccslmlrratcs/Reconds or decimal degmes: 22.Certification: rt rt, r((lCE$�(r,�G UiJI
t trren held,cart hdnon8 is sto&ierA)
N ;' -Brian-Ewing.- 10/13/2021 N
Sigratum of C4;4xd 1�lell Covomtot Moe
6.Is(are)the wetl(s): JPermsneut or MTemporary By Signing this form.thereby certi&th&the units/st*s 1"rel torntrratred In mvorlanee
w&h 15A NCAC 02C,6100 or MA NCAC 02C,0200 Well Comemaimi Srandords mtd Haar d
7.is this a repair to an exist well: oyes or NNo copy of thir rtrnni kos brew provided ro Ow m4l owner,
if Ah it a repair,fill otrr kwmvi waif trne'rrutvlan infotawat NT and rtpdaba achy narwe of the
repair amler tr2l reemrEs m7rm ar an the book of fJds form. 23.Site d tagrom or additional welt details:
You may use the ba&of this page!to provide additional%%vfl site details or%yell
S. umberof wells construeted• 1 construction details: You may also attach additional pages if tres:essanv.
For ma ddf r AtftrAm or new-vtwerwlaplr arils ONLY v4A rhea~t+otrsdraction,you tvm"ibmitonefim. RC B 7"i At.f [N,STQCTIONC
9.Total well depth berms land surface: 24 (11J 24a. For Ap Welix StibnAt this form within 30 days of completion of well
For maftiple myth Hir all depOo lfdifrerenr(t mpfe-3s@2fV nud 20-4a9l construction to the foltossii ;
10.Static water te%-el below trip of casing: (ft.) Division of Water Resources.Infortaation Processing Unit,
lfpurer kwel it above rating,au"a" 161711dail Service Cater.Raleigh.NC 27619-1617
11.Borehole diametm.2.25 (in.) 24b.For inWan Wel1e ONLY: t in addition to sending the form to the address in
24aaboye. also submit a copy of this fofm within 30 days of completion of well
t L Racll construction mobod: DPT construction to the following:
(l.e.argcr.ratatp,cable dims pusk etc.) Dh,hlon of Water Resources.Under vond Irifection Contrail Program.
FOR NVATER SUPPLY WELLS ONLY: 1636 Mali Service Ceoter.Ralelgh.NC 27699.1636
13a.Yidd(gpm) bledrod of test: 24c.For Water Sp EDIT aye lnfa4itm Wcft
Also submit one copy of this form within 30 days of completion of
}�13b.Disinfection ty Amount: well construction to the coimty hcitlib dcparinwra of the county where
. confitructod.
Form GW-1 Noah Carolbm Do{p incM ofEavirwunco wd Nanwat Rcsowms-Dian of Wratcr Remum Rcvbcd August 200