GW1-2021-08022_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For ftrremnl Use ONLY:
TT,is fortnwn be used forsingle or mulliple wcUs
1.well Contractor information:
t t u► IM ts
Brian Ewing FROM TO DPSCRtPfI
11'tllContrvdofName
4240 B
ft. fl.
NC Well Comwor Certifictition Number AtOUMCAMMOormukkawd , OR "bk
FROM TO DIAMrMR Tft►C KNfSS MATERIAL
SAEDACCO Inc 0 h, 21 (L 2.25" ta. NA STEEL
Compruir Name 16:=MIR CASINGOR TURING ewhier al claseda
FROM 170 1 DIAAIF•TRW THICINES3 MAI=AL
2.Well(ondlmtinn Per mIt N: (L R.
List all applicable writ pmn(ts f Le.("mrnh•,Stan.%% ance.Irlf en rm.) R.
3.Well Use(cheek well use): 17_S
CRUN
water Supply Well: FR M TO t/1A3l9Tt:R St,OTSI;Z 1111C1CNtMS MATMIA1.
DA1grici tUtal 67Municipallftlic 21 ft. 25 ft. 1.25" IN, .004 NA STEEL
CGeothemlat(HeatingCooling Supply) DResidentiat Water Supply(single) A• fL is
D iudustriaUCotnutercial DResidential Water SuppKy(simmil) I&GROUT
FROM 170 MATERML EMPLAC MINT MOMOD AAMOVNT
Dlrtf ion rt. fL
Non-Water Supply Well: e
MMonitorin ❑Rccovc
Talon well: it. fL
DAquifcrliccharge DGmundva ter Retnodiation 9.SrWtS. RAVE1.PACKftr kalife
rR M I RIAMMI. VMPIA,.1i:VTMRTN tl
QA(pufcr Stomgc and Rcco%rq Malinity aarrict 0. fr.
❑Aquifer Test oStolmltiiter Drainage
DENpcd=cntal Technology oStibsidcrlcc Contit;l
i
2r1.AR:li.IJNCiIdfCr suit+e6additlondl:elkelait+eeeessy
Meottxttual(Closed loop) 17Tmcer FROM 1O DFSCRFIt1ON toobt.bar#"wwock ere
OGeottmmal(Heati oolir Return) DOther(explain under#21Rernat&s) 0 (L 10 (1. FILL SILT SAND
10 M 15 ft. SILTY SAND
4.Date Well(s)Completed: 10-29-21 Wdlmassw-GW-11
15 ft. 25 h. MOIST TO WET SILTY SAND
3a.Well Location: (L (t,
Former Charlotte Army Missile Plant
Facilty)OwoerNome Facility]DO(if applicable) .
Ain
1824 Statesville Avenue, Charlotte, NC, 28206 n p-
Pbnysicat Addmss.Cah,.and Zip Zt R
Mecklenburg SP-22 PLATER SAMPLE. !r•1A SELrIU !
Caatny Pared ldetd fkattonNo,(PIN) ! 1 CESSItV
Sb.t afitudc and LonglMde in A inntcslsc�nds or decimal d rccs
m � 22.Certification:
(Ifxeltfield,om t-Anoit is pi0e'iem)
N w Br-i.a;n Ewing 11f2,2021
Sipwi n of Cenil'iod'Well Contractor Oak
6.TS(arse)the well(s): MPermanent or E Temporary fn iiong this form,l herein,rertt6-that the nr111s1 war f m-red constnrered in aredrdaner
dvrh 154 NCAC 02C.0100 or l SA NCAC(r-C A201 N`rN C.ansoverion Standards and shut a
7.Is thls a repair to an existing well: oyes or MNo rnpraf tits sword hos&rn parvirW to she nrAl r wner,
lfM6 4 a orptlr,fill our f0fino t well constnrrrfan ig0MW*N1 evul exploln the anrure of Oar
reWir under#21 remari-ss rtrnn or m the hark of this form 23.Site diagram or additional well details;
You may use the boil.•of this page tolprovide additional well site details or well
ti.numberof Bells constructed: 1 construction details. You amv also attach additional pages if necessary.
P t�e fn trife dmi a non •-%wtr sjTj4 arils ONLY�/rli rite across eonsrrwcrlan,you arm sawt SUR f•1•I A L.INS7 C1C 1'IONS
4.Total well depth below land arrface: 25 (fL) 24a. For All welts: Submit Olds foam within 30 days of completion of"tit
For multiple wills hArofJ diphs(fdifli-rew(,rxow hfe.?@200'and,?@ 10ff) construction to the folhnsing:
10.static WSW le%,d below top of callow (N Division of water Resources,Information Processing Unit,
if acme leerl is above rvsalng,use"+" 1617%fail Smiec Center,Raleigh,NC 27699-1617
11.ilorebtrtc Aianneter 2.25" 010 24b.For 111W ton Weds ONLY, In'addition to settling The fount to the address in
24a above. also submit a copy of this form within 30 days of completion of n%ell
12.Well construction method: DPT construction to the following:
(le.atigar. otary.cable,dind:pusti etc.l
Dh•islon of Water ReswrecS.Uodergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai)Service Cent,Ralelgh.NC 27699-1636
13sL Yfdd(gpm) Method of test: Uc-For Water SDWly&Inj_e thm Wells
Also submit one copy of this form Mthin 30 days of Completion Of
tvetl construction to the county health department of the county where
13G.Disinfection type Amount: constmcted i
Form G\V-1 North Camlim D.W m of Ent-imiunew aid Namral Rcmwm-Division of Water Resoucs Revised Atilt st Nl l