GW1-2021-08017_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used flan singic or mailliple wells
1.Well Contriwor information:
.UWATSAZOPl
Brian Ewing FROM TO at RIPr1ON
t3°tTl Contra"Marne
R. ft.
ft. fL
4240 B
NC Well Contractor Certification Nusmcr 15.01(im ASINN(Ifforeu►Ifloo d by 3.WM tf` Ilea
FROM To DTAMKM Ttti MATERTAG
3AEDACCO Inc 0 tL 26 fL 2.25" Is. NA STEEL
Casgpsun lYante 16 OR TV1iiNC Itettu>ft c
FROM 170 DIAMETER I THIt h"ass MAIMAL
2.Well Conttraction Permit R R. ft. Iin
Lisf all appfiniNe will peruritt tire.CawnN,Stair.L'ariartre,IIifB en etc,i ft. h. ill
3.Well Use(check well use): 17.S, N
yll$terSnppiy'Wcll: FR M TO DtAptRTr,R; 3tOTtitrR THttICKRSS MATRRt4t.
DAgOcultural ONInicipal'Pnblic 26 R. 30 (L 1.25" la .004 NA STEEL
DGeothenmal(HeatingXwling Supply) OResidential Water Supply(single) R. ft. In
Dlndustrial/Comn=ial aResidentiai Water Su J GR
Supply(shared) FROM I TO ?RATER"*"*L EXPIAC CHM. METHOD A AMOUNT
0brigation ft, fL
Non-Water Supply Well:
h.
MMonitorin Ditocosr •
Injection Well: h. h.
DAquifcrRcehargc DGmundsratcrRcmedintion 10,SAN IGRAVR1:TAG1C f tlti to
FROM 'm I MAT RtAt. KNptA. rF�th11'rttpD
❑Aquifer Storage and Recovery Milinity Harrier ft. ft.
OAgk0fcr Test QStorlttnmer Drainage
R. tG
DEsperimcnialTahnologr DStdasidenccComml
MDRiWN`GLOG ail»ciwvWtI**WskvtsJforcessa
t7tamtbemr3l(Closed Loop) ❑Tracer FROM TO DESt' W"ON tatar.bAt+am s,aumea *a.OR.)
OGeodienwl(Neoth Cooli Retum) OOther(ceplain under A21 Remark) 0 R. 25 fL FILL SILT AND SAND
25 ft. 30 fL SILT WET PWR
4.Date Wett(s)Completed: 9-25-21 Well jD#GW-2
(L ti
St.Well Location: h. tL
Former Charlotte Army Missile Plant
Foul ta/Ownev Nana Facility 1D8(if applicable) V V
1824 Statesville Avenue, Charlotte, NC, 26206 R. R '
Pt0'sicel Address City.and Zits 3t,ltfrlt
Mecklenburg WATER SAMPLE W/SP-16 pynnf
County Parcel IdeldificationNo.MN)
Sh.i.atitodc and[rigitadc in dc)+tecs/mInuteslseeands or decimal de pvm. 22,Certification:
(Irwev field,Otte htt7anrg 10 sufltckiri)
N W 10/13/2021
51grot mofCertifiedWdlContactor Date
6.1s(are)the weil(s): oPermanent or ZTemporary 4 signing Chit flank 1 hereby croi,/v tliw the wrib(s)was tars.)comirarred in nevordm ee
with I4A NCAC 02C,01W err 154 NCAC 02C.p2M tl'ell Conor w0wo Spiel rrds aiwl.dwt a
7.6 this a repair to an errisfing well: €7Yes or ENo ralsr of thin retard has peers prrwidrd to the urll anwer.
Ifshls hr o mwir,fill out kno m well main nwdtoa hVomwtkut and explain rhr narnrr of die
rgwir under 021 rewanU srrfian or as thr back of this farm. 23.Site diWaIn or additional w ell details:
boat may use the ba&of this page to provide additional well site details or well
8.Number of hells constructed: 1 cDustmCdon details. You inay aW'Atlach additional pages if neressm.
For mutrlplr lrtjecrh-m or entt•nmrr satpPh wells ONLY+;Irh the saute constmrdon,+on can
su mnit erne form. SUBiNYTTAL UNSTLM S
9.Total well depth below land surfaea 30 (ii.) 24a. For All Wells: Submit this form within 30 days of completion of%til
Form.01ple wells list affdrnrtrslfdljferrrn(ermnPte-3@2(K)',md20lotrl construction to the foilrming;
let.Ststiie stater Invi below top of casing: (ft.) Division of Water Resources,Wartnation Processing Unit,
ifumrnr level IS aJ fire rdsing,wsr••+" 1617 Mall Semiee(`.Enter.Raleigh,NC 27WJ-1617
11.Borehole diameter 2.25" (io.) tab.For lnlZilon Wells ONLY: in addition to standing the form to the addrtass in
24aabove, also submit a copy of;this form within M dm's of completion of Weil
12,Well construction method: DPT construction to tit following_
0x..auger.rotaw.cable,direct push ew.}
Dh•lglon of Water Resources,Underground tnJectiot!Control Prog►•ttm,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serriee Center.Ral ft.NC 27699-1636
13a ><c!d(glom) lt4cthod of test 24c.For Water Suppis&injection Wells:
Also submit one copy of this form within 30 daysof completion of
13b.Dlslnfcetion type: Amount: urli consintction to the county tt aith department of the county whcte
constructed.
Fonn GN'-t North Carotins Dgxtaracia of Emiro meld and Nantnal Resawc s-Division of Water Rek u'm Rc%iscd Attgttst 2*I.1