GW1-2021-08018_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For frarml Use ONLY:
'Mis fortncan W ased for sitigle or multiple sells
1.Well Contractor Iitformatloir
ti.WA'#'RR ZQ
Brian Swing FROM To D IrriON
%VellCantmcto?Name a. to.
4240 B A. IL
NCWdICornrcaarCc-nir=tionNumbei I&OUMRCASINfi nrtnadiatxdate 4R.t.IIYFIt 15cabk
PA M TO 111M METER TRWKNM MATERIAL.
SAEDACCO Inc 0 (L 26 (L 2.25" It. NA STEEL
Ca+opaily Name 16.I CAST OR TUBING 4geotlietast elmd-too'
FROM 170 1 DLOTFTFR I THiCA-4TS$ I MAT[ALAL
2.Welt Construction Permit R". R tt. 6►
Lim all appliruNe MxH pemdh tie.Coanh,Starr,Variance.Irfe ecia esr.I
3.Well Use(check well use}:
Witter SupphrWdi: FROM TO DiAMRTBR 5t Sf71E 711(1(NM I MAT6MAL
DAgdafittirul QMtmicipal}Public 26 ft. 30 R- 1.25" la .004 NA STEEL
QGeother al(HeatingfCooting Supply) DResidential Water Supply(single) ft. (t. in.
Olodustrial/Commercial OResidential Water Supph,(shated) Su{TROUT
FROM I TO MATP.RiAL TWEA[EMtMT METHOD A AMOUNT
❑hr( tion n, IL
Non-Water Supply Well: R.
MMonitoring 011ccolcty
In on Well: R. iL
0Aquifer'Rccharge C10murxhtutcrRemediition It.S 16K RAV LPA f be
QAquifer Stoingeand Rccotrry OSalinity Harricr FROM ft. To
To Mn ,RFAi. VMVIA UNTMrTntln
QAquifcr Tcst QStarrlmancr i tainagc
❑F:prri mental Technology ❑�tsd cnce Conrol
20,0111:1140C addlilansttdn ftIf
oGeothermal(Closed Loop) 13Tmcer .FROM TO DE"Her70N(tour.110rd"v%Wwtwkn itMwelr.
OGeothennal(HeatingCooling Return) OOther(t a ain under#21 Remadts) 1 0 h- 10 ft. FILL SILT AND SAND
25 f. 30 h, SILT WET PWR
4.Date Well(s)Completed: 10-6-21 Wd1IDd(1W-22 H. IL
Sat.Well Location: (L (L
Former Charlotte Army Missile Plant n, IL
Faci1in,MMr Nrux Facility IDS(if atppbubW)
fl. tl.
1824 Statesville Avenue, Charlotte, NC, 28206 k, p,
P"icut Address.C"y-and Zip 2E M1
Mecklenburg WATER SAMPLE W/SP-22 MR SECTION
Caatqy fiarcd tdtul;tkaUnn Nn.(PIN) .�
'" RnCE.SSING UNr
51n Latitude and Longitude in dcWteslminutc0sceondsordetlmal degrees: 22.CeetificatinD:
(if vien ftetd,one h%lota it sidlicktai
N W Brian Ewing w 10/13/2021
situofCctt"tfrcil encawwtor ��� n- Dmir
6.Is fare)the nell(s): QPerinanent or zTemporar}
M'slFnirix able form,t hentrji rerhh that The n+rll(s/ams(iairrrl eanstrsrated in a[-rvtrdimer
idrh 15A NCAC 02C.0109 or 154 NCAC 02C A20o ttell Cnnsemcdon Standard and shay a
7.Is this p repair to an existing well: f7Yes or MNn axTry njrhir m arri hns`bern pravided rn the»rtl mrnrr.
ljrhls it a:rptrlr,fill aarknoavr M•rll rmurrrnvPan igjamarrMn acid r_r{daln rlrr turrarre of tree
repair is der d2l rmarks o-e ian or an the bm-k of thix farm. 23.Site diagram or additional well details:
You may use the back of this page to,provide additional avll site details or well
S.Number of welts constructed: 1 construction details, You may also ausch additional pages if tlecessavy.
Fnr mrMple Injeerkm or roan-Mrrrer ssq!plr wells ONLY uJrh the secrete roirArartfom,,vane CM hi[TTAE.
vubmirmteform, SUBMITTAL iNSTSft^TIONg
9.Total well depth below land surfaces 30 (n,) 24a. For A Wells: Submit dais farm mithin 10 days of completion of well
For matedpkwrilslin all deprhffjdijrrerrmfewmple-3@200'aM2@1W) construction to the folkawing;
10.Static water tare)below top of rasltq,- ((t,) Dhislon of Water Resourstm Information PrDcesWng Unit,
If inter MrYI Is otrave+nsfa-' rase"+" 1617)trail Service Center.Rnldpb.NC 27699-1617
11.Borehole diameter 2.25^ (to,) 24b.For inWWon Wells ONLY: tfi addition to sending the form to the address in
24a above. also submit a copy of this form wilbin 30 days of completion of well
12.Well contraction method: DPT constnwtion to the following:
(i.e.super.stir-,cable.dire i push ctc.t Dhision of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serviee Center,Raleigh.NC 27699-1636
13a.Yield(Rpm) Method of test: 24c.For Wafter Supply 6t Ipjecthm Wells:
Also submit one copy of this form ivithin 10 days of complexion of
13b.'Disinfecti+in type. Amount- well construction to the cDrmty health dcpsrtmem of the comity where
constructed.
Form GW-1 North Carotim Elgattr teaa of Fanitma mem aid Nanual Rewumes-Division of Water Rexou•o-- Rc+•iscd AtCM 20IA