GW1-2021-08014_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For irkrmi Use ONLY:
Th's form con be awd rar single a multiple wells
I.Well Contractor Information:
ti RrAT6t3: Nam.
Brian Ewing PRp►1 TO Drs(lumox
well cotttruto.Naar n. h•
. r.
4240 B ft
NC Well Cortlmdoreenir=trooNumbet S.Oi1TM G arrraiki•d9rd*vlli OR if urtb
FROM TO DIAMETER THICA'h'P.SS MATERIAL
SAEDACCO Inc 0 (L 21 It, 2.25" it. NA STEEL
Comp;uq-Nan* 16.#NM CASINOOR-TUBING ' --tertle$boned
FROM TO I DIAMETER THICILNISS MATERIAL
2.Well Construction Permit k: ft. h.
list all applirnrrle writ prrmits(i r.Cawnryv Statr,t ariamrr.11j r$arl rir.J
3.Well Use(check well use) 1=
Water Supply Wtlk T�"
DIAMeTPR $)TSn? IIM14 SS MAMfAt.
DAgricultatat 0municipal[Ptlblic 1.25" im .004 NA STEEL
taGeothermal(Keatin04oling Stipple) [)Residential Water Supply(singie) to
DindustriAUComnnerciai ORcsidcntW Water Supply(shared) I&GFROMROur MwTE>ttAt. EAIP11lC V1 Sr TO METHOD A AM01;W,
131ni tion ft. (L
Non--Water Supply Well: R. It
®Monitodn [Acco-y-cry
Injection Well: h; d.
DAquiferRccharge OGlounduverRcmediation 1v:SAW" PACK kab
❑ quifcrStomgc and Rccov ry ❑Salinity Banict FROM R. To ft. MATERIAL .VdP1,AM1KNTM TTt o
0Aquifer Test OStomm-rter Dminag:
❑ENp:rimental Technology ❑subsidcace Control
3itl,:DRl1.1dNt3LOG ai ti�tlditi�iatabedsN.
❑Geothemtal(Closed Loop) OTracer FROM I TO DI1seRrvno� e►b+:u.rrne tuat+nfk a errt
Meothermal(Heating/Cooling Renter) OQdier(otplain under#21 Renatim) 0 h• 10 h. FILL SILT AND SAND
10 h. 25 h. SILT WET PWR
4.Date Weit(s)Completed: 9-26-21 well ir-W-5 r. It.
Sa.Well Location: (L h,
Former Charlotte Army Missile Plant
Facil/O•wner Name Fwilq IDR(if applicable} h. h
1824 Statesville Avenue, Charlotte, NC, 28206
PID�skal Addrtss City.and Zip 21. M
Mecklenburg WATER SAMPLE W/SP-16
C autoy Pattelldertl ficallon'No,(PIN) (tar tit(��C,11�iN
r ,
Sh.latitude and I.on r`c SG r ,kitadein tiegreea/rnillotlralact:dindsorAtxlmal d 22.Ccrtif�atir►n: tiG UtJ(
(if Y01 Iktd,one bOotC Is SrtttttiGid)
W Brian_ Ewi.ng.—. 10/13/202
Sigreturc of certified Well contractm Date
6.iS(tire)thewell(s): ❑Permanent or MTtmporary By sisninp Ab fionn.I hark-ready that Mr nvf4s!terms fwrrr)twnrtruilyd bt airwnlanre
ndth 15A NCAC 02C.,Oin?or 154 JVCAC MX,t72OO Bled Constrwrtion Standards and drat a
7.1%this a repair toanodsftwell: 01'es or MNn rnppnfrhurlrnrr/has!>,e+tprmirTrdrniRruwl!mittrr.
Jf Ails is o repair,fill car known a dl eoarrnriim 1gfon w4mi mud r rpiain rhr norm"of rhr
rfpairvnder6 l rrowAs swAmr fir on thr hark oJrhis farm 23.Site diagram or additional well details:
You may use the back of(his page!to providfle additional nv:ll site details or well
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary
For multlplr igfMilnat oe wo-4wrer,sgyp v wells ONLY nVrlt rrrr wme onnsrruC&R,wtw can
sutm+mit one form. S�(M 7,`ULINSt°UCTTONS
9.Total rrdl depth bckrwland surface: 25 (ft.) 24a. Fbr All Wells: Submit this fowl♦within 30 days of completion of well
For msdiVe calls tin all depths!f d!f('rrrnt(example-J@ZOO'and 2010tr) construction to the following.
10.Static water leve)below top of casing:_ (ft.) DiviAnn of Water Rccou rem.Information Processing Unit,
If scrim level is above intlntt,am"+" 1617 Mail Service Center,Raleigh.NCC'276'391617
1L Itomboic diameter:2.25^ (in) 24b.E4I.InkWQU Welk ONLY: In addition to sending the form to the address in
24aabove:. also submit a copy of)his form within 30 daps of completion of weli
12.Well construction method:DPT construction to the following_
(i.e.auger.rmary,cable,dirm posh etc:)
Dlt•Islon of Water Resattrces,fUndctgt+ourtd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center.Raleig NI C 27699-1636
i
13a.Yidd(upm) Method of test 24c.For Water Say it�r dk to[octiori Wells:
Also submit one chop of this form within .10 daasof completion of
13b.Disinfection trpr~ Amount well construction to the cnmty hctahh deMitment of the carnh where
c ristructcd, I
Form GW-1 Norib Catalina Dgx0roemof Emv manrnuaid Natural Resources-Divabn of Wald Resoam Revised AtVM 2013