GW1-2021-08016_Well Construction - GW1_20211122

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WELL.CONSTRUCTION RECORD for tuhemnt Usc ONLY:
'ibis form can be nscdlot-single or m Ilip'k wens
1.Well Contractor information:
t4 WAT6 20NRS
Brian Saving room Tn 1 D IF1T9V
w'eiI Cotrtraxim Name h. ft.
4240 B
NC WdICormactorCenifxmtionNmmcr V&OUTRR CASING(for:a"ui11-asrdiweli 'ORL7N13t if smash
FROM TO mAMRTfR TITiT'MNS15 MATERIAL
SAEDACCO Inc 0 h. 26 (L 2.25" in. NA STEEL
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Cotmrpany?4rw 36.L CASINaOR.AVRING iii iloseaa
FROM TO DtAHETRR TnICI INS!; MATERIAL
2.WeltConstructinn Permit th R. ft.
l iu all applicable.well permits(cc.Coum<*Sorer,Irariatwe.lift an o1r.) R. h, in
3.Wdl'Usc(check well use); s7 N
WaterSupplp Wdl: FROM TO mAnfF,raR SIATSIFY.. TIIi NtS, I MATF,RIZ
DAgriculwal ON[unicipal/Public 26 h. 30 h; 1.25" la 004 NA STBBL
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(7Geothetmal(HeatinglCootirig Supply) OResidemiai Water Supply(single) R. IL in
OhndDsttialtCommercial DResidential Water Supply(shared) tR'URa1TT ;
FROM I TO MATiiRiAL EAIPLAC£MLNTMETIIODAAMO[tW
131rri tion R. tL
Non-Water Supply Wells R �
mMonitorin DRcxavr
Injection Weil: R• h-
DAqu fer Recharge DGmundwater Remediation 19.SAND11GRAVEUPACK411 ht
'FROM 'r0 MATRRrAi:,: rt:AM.11NTMr:r"00
OAsiaifecStoragaand RccoNcn OSalinity flamer R. h.
❑Aquiter Test OStomm'ater Drainage
R. it.
OEapetimcn(al Tochnology OSttbsid=c Control
20.bR1LtJNG ft)tiz Iaftaclt adititloniil sif iaecessa
i7Geotbumal(Closed loop) ❑Tracer FROM TO DES oMur.hordn. ybWowit tlrre.eu
OGedtltemtal ffleafingACootiM Return) DOthet(explain under#21 Remaiks) 0 R. 25 R. FILL SILT AND SAND
25 R. 30 h. SILT WET PifR
4.11ateWell(9)Campleted: 9-25-21 Well 1D#GW-3 ft. IL
Sm.Well L ication: h. It.
Former Charlotte Army Missile Plant I' tL
Facjlht,OwwName Facility•iD#(if aypticabac)
1824 Statesville Avenue, Charlotte, NC, 28206 R h.
PiWskal Addiess.CSh.and Zip 21,ItMI ;ff
Mecklenburg iPATER SAMPLE N/SP-16
Cewnty Parcel Identilkatton No.(PIN)
4b.1.slitudc and Longitude in dcgrecalmirtutalseconds or decimal degnw. 22.Cc.��- on: fn rP �tf�a�SL(;l i f
(ifwetlIkId,osae I-Wong a
N W Brian Ewan 10/13/2021
Sigavarr ofCcniftod Wefi entmetor Date
6.1s(are)tbe.wen(s): DPermanent or ZTemporat7' ga-signing this form,1 Armby errtify then the im-fits)wvr{wrrei cerai weed in at"nlmier
with 1 SA MCA 02C,01 M or 1 SA NCAC 11 C 4209 it ell Cotrumrtlun Standards and slurs o
7,ix this a repair to an existing well: Ol'es or MNo rufy c f diit reroml has bem pmridrd rn the urli awner.
lJthts is a rrl+elr•fll lout Rtntwtt well conon don lnfijmwrkrct awl rrptain the nerarr of the
rrlsait[later r>2l rrx°arnFs srrlfms rn rwt the hurls of shay farm. 23.Site diagram or additional well details:
You may use the back of this page;to provide additional weti site details or well
8.Number of wells constructed: 1 construction detail. You inky also attach additional pages if rxcessary.
For maltrple A{(Mtl m or w#j-tt`art,r sWply wilts ONLY ul A thr fader eanstrwedon,yaw Can
submit one form. SURKMAL iNSTUCTIONS
9.Total well depth below land surface: 30 (i1,) 24a. For All Well Submit this'form m thin 30 daps of couiptdion of uttt
For maidplewellsAsralldrprhslfdffranttermVhp -.1@200'and2011W) consinietionto the foltowinS
10.Static seater Intl below top of cesiuV (n,) Division of Water Resohrees,Information Processing Unit,
if rarer level is about casing,,use"+" 1617 Mail Service(inter,Raleigh.NC 27699-1617
11.Borehole dismetcr 2.25° (in) 24b.For inkWita&Llb ONLY: In addition to sending1tre form to the address in
24a above, also submit a copy of this farm within 30 days of completion of well
IL Well construction method: DPT COnStroctiau to tilt follocring:
(i.t.Mtatt ratan,,cable,dirmfush etc.)
Dh'islon of Water Resourccs,X[nderg•oond trajection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Scnice Center;Ralco.NC 27699-1636
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13a.Yield(gpm) Method of tat: 24e.For Water Sutnris lR Injectioni Wells:
Also submit one copy, of this form within 30 days of completion of
13b.Uishillmdon Ivan: - Amount-. _ - well construction to the comay hearth departawd of the Comm when
constructed,
Form Gilt-t Nodh Carolina Dgwinictrt of Emimnsta.tu and Natural Rcsowm-Dhision of N'ater R'e owce; Rc+'lscd AL%La 2013