GW1-2021-08020_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For tttcnlml Use ONLY:
71is fonn can be used for single or molliple wells
1.Well Contractor Information:
14,W'ATRR IONtS
Brian Swing FROM TO n 1Prmx
WO Conrtracwt Name Q. R•
4240 B
NCVkfdlCo1etlrtlorCenifteationNumber I&OUMCASM010fortrnatN lifonblkabld
FROM TO DIAMETER: TWrK!'Fss I MATERIAL
SAEDACCO Inc 0 fL 21 ft. 2.25" in, NA STEEL
C,otn�ut)•Nad1c 1t;i lrrtr.o>t:�u�imO aratl,emnreFc a .
FROM TO I DIAMETER SS TriCKN MATERIAL
2.Well Construction Permft st: ft tt. in.
List all ir31 Wrablr atoll prmrits(i.e.Goanty Srato,Va►ianrr.Irtfecoat rrr.J ft IL
3.Welt Use(cheek well use): *�s ccrt,
Water Supply Wdll: M-fl
RIAMITER SL.gTSlrr: 7111(7tiM5S MAT IAL
Oftficultural DMunicipal/Public 1.25" IIL, .004 NA STEEL
C)Geothermal(BeatingCooling Supply) DRtsidential Water Supph'(single) In
aindustrial/Commcrciat nResidential Water Supply(shamd)' &CROP
FROM 110 MATERIAL OIPLACEMLNT METHOD AAMOINr
13hfization n. n.
Non-Water Supply Well: IL
mman torin ❑Reco%c '
Inject oD ell:
QAquIfcrRcchargc DGroundituter'Rcmaditnion D.SAIVD CP
_YN M TO MATRRIAI. P,MPLA .. ExTMr�rtr0n
13Aqutfcr Storage and Rccovcry ❑SelinityBorder R. ft.
❑Aquifer Test ❑Stommatct Drainage
OExprdn=tal Technology Mubsidc-ace Control
20.;DRILUNULOG attoeb GBillonaletuclaN
OGeothermal(Closed Loop.) OTface r FROM Tp DFscRrrmos: air esranc�,>futiron ii r
DGeothernlol(Heating/Cooling Return) 00thet(egolain under#2iRemadts) 0 tt. 10 tt. FILL SILT SAND
10 fL 15 ft. SILTY SAND
4.Date Well(s)Completed: 10-29-21 WdlID#SSW-GW-13
15 n, 25 tL MOIST TO 1PST SILTY SAND
$a.Well 1,Aleat{nn: ft. It.
Former Charlotte Army Missile Plant A. fL
Fac41hyiOnncrName Facility]DO(if alppiimble)
1824 Statesville Avenue, Charlotte, NC, 28206 R (L
Pkskal Addtess.City:and Zip 37.1 EMU
Mecklenburg SP-22 WATER SAMPLE.
County PutTd 16mifkAHpa Na.(PIN) 1P_A dA 6VMb rG t l0P;'
Sh.i.atitudcand Longttudc in degrees/mirmtrslscainds or decimal degm= 2L CertTkation:
(itacil/iCt4,one ku1o"S is pdtleiera)
N W . B.rian Ewin. 11 2 2 a21
11-
Sig==ofceniP;cdWdlComnactor nail
6.is(are)the weli(s): E]Pmnanent or .I'fempormly yp fions'hit u form.I heron•errtih Char Me v#*44s)carat(wetr)vorattrwrud in arrordm ee
with I JA NCAC 02C,01M or 1SA NCAC NX,0200 N'zll CoxarrntWon Srrar4tirds and Aw o
7.Is this a repolrto an E%istdDg Well: l7Ye s or MNo toprofdrir record ho been prmidnd ro rho aril rmvwr.
1lrhla is a r�:perJr.fill cwl knoxw Krtl e+mnrrructtao i>rfeirn+ark�ur soul r>rptain tilt+rurrarr ojrhr
repair w rder*21 mwwrb arrrhaa or an the bark of tAfi-f vrm. 23.Site diagrum or additional Well details:
You mW use the baek of this page to ptolide additional well site details or well
1I.Number of wells constructed: 1 construction details. You May also attach additional pages if necessary.
For rrnaltilde Irt jeerkm or Non-%wer supper 4-e11t ONLY n-&h the were eonstrar4m,ynH eon
submit Mir faun. StlBhiMAL INSTUCTIONS
9.Total well depth below land surface 25 (ty,) 24a, For A Wells: Submit this ft mt within 30 days of completion of well
For muttiplr wells lin all deprht fI dtltrrem iex p1e-J@2W'wed 2611(r11') Construction to the folloning;
10.Static water ImvI below top of casing; ((t,) Division of Water Resaureen,Information Pmcescfag Unit
if Nnrer hovel is akwe eddol,we"+" 1617 Mail Sen'iec Ce:nfer,Raft:0.*tC 27699-1617
11.Rombole diameter:2.25° (irl) tab.FQr inlerHon Weill ONLY: In addition to sending The Coral to ft addiess in
24a abiwe. also subunit a copy of this form within 30 days of completion of well
12.Well construction method: DPT construction to the following:
(i.e.angr.misty,cobte,dhd posh etc.)
Dhislon of Water Resources,Ur derg round Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen9ce Center_Rolft,NC 27699-1636
13a Yield(Rpm) Method of test 24c.,For Water Supply&injection Wells:
Also submit one copy of this turn titiihin 30 days of completion of
13b.Disinfecifon type. Amount: well construction to the county health department of the county where
constructed.
Fann GW-t Nonh Carolina Dopmtwxm of Emironnrla and Nanaat Resources-Division of LlIatenRew rm Ret ised 4t(gtbt 2tt13