GW1-2021-08024_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For itarml Use ONLY:
'tltis:form can be mW for singic or multiple wells
1.Welt Contractor Information:
i4. ZONES,
Brian Ewing FR M 'M DPS rP11O.;
UIeltControctarName
4240 B
NC WellConundorCenifecstionNumber tS OUTF.RCASiNG ramuttlasedwtlls OR:LWER If file
FROM TO PIAAtMR 1TM" FSS MATERIAL
SAEDACCO Inc 0 h, 21 fL 2.25" im NA STEEL
Gotrtptui)•NAMe If 17NM CASINOJOR 71)BING4kedliemid plawd4labol
FROM TO DIAMETER TH1M*'6Ss MATERTAL
2.Well Conexr action Permit N: R. ft.
tut atlt opplirnhlr writ permlo l.r.G'nanh•.Stith;Vnriawr-ll scum fir.) R. fL iia
3.Well Use(chedc well use):
Water Supply Wdh FROM To atAnrBT9R st sl77 I '"IlMl MS MATMIAl.
OAgriculturat LMuniclpallPublic 21 R. 25 (L 1.25" Itb .004 NA STEEL
l'Jt:reothetmai(HeatingACooling Supply) ORessidential Water Supply(single) R. R, hs
DindustriaMmmerciai OResidcn upp tialWaterSh•(shamd) t FROM
OM TO MAT@RtAl: ErTPtACTrSMT M£7110D 14 AMOUNT
Dhiigntion ft. fL
Non-Water Supply Well: fL A.
mmonitorin Oitocme
injection hell:
DAgttiferRecharge OGroundwolcrRemediation 19.SAND VBL P lead►e
O Aquifer Storage and Rcca%ery ❑Salinil\•Harricr FR M MATFarAr FMPt A(CA1K T Mi rH n
R. ft.
OAquifer Ticst ❑Stour mm-atcr Dmimp:
R. fL
Ol Verirracntal To:hrrologr 05itbsidcrce Coattrol DRt1,13NQ LOG torch adMitmifl beds lfaccem
13Geotherlai(Closed Loop) OTracet FROM IfO DtsscRrlrnO� osl r.aarrnea wanes tvr
❑Geothenuitl(Heating/Cooling Return) oOtha 4elplain lender#21 Retna&s) 0 eta 10 h. FILL SILT SAND
10 ft. 15 fL SILTY SAND
4.Date Wetl(a)Completed: 10-28-21 WdI ID#SSW-GW-7 15 fl. 25 fL MOIST TO WET SILTY SAND
Sa.Wall Ltrcat)nn: fL R.
Former Charlotte Army Missile Plant fL fL
Facility10u•ner Name Fwilhy IV#(i[appltable)
fL ft.
1824 Statesville Avenue, Charlotte, NC, 28206 f{ RNov
P14aicet A(tdtess C4-and Zip 3t.' I INARICS
Mecklenburg SP-22 WATER SAMPLE. it,rP DVVR SECT
IOAj
Count)' Pamd IdletaifseAt on No,(PIN) !ln(�FS.Sh'�Ci
Sh.latitude and Longitude in degrecslminutcslscconds or decimal dtxreat: 22.Certification:
(ifueu hell,omx Wlong is stdt)eio!)
N W ,Brian�.Ewing... 11f2f2021 M�
sigmtere ofCtnifmod Well Comrartot Date
6.is(are)the tsell(s): oPermanent or zTemporary gr 6igninA this farm 1 ltrreJi}eYrtiA_rhat she my-14s)wvs(«seer twrointered In aecordararr
w•Ith RM NCAC olC,n 07 ar-1SA KC.AC NIC,0200 RkU C,nnsrrtunisn Starutards wid dwri a
7.Is this a repair to an etdssft veil: OVec or MNO rnps nfrhbt evened hasbrrn ptnrukd rn thn`:nritnw+rrr.
if this Is a repedr.fill out k wit well ron meitan Information tmd rk*h die omwe of rhr
repair under621 remarks sretiam or on the bar*of this farm. 23.Sias dlagnm or additional well details:
You may use the back of this page to provide additional well site details or well
8-Number of wells constructed: 1 coustmction details. You may also attach additional page if necessary.
For maldtdt loWAm or nram•nwer jWple writs ONLY n irh the smite C0nAWW1kn,W+t can
submit me,foram. S.42i3SHITel►i111Y5fiUC17ONS
9.Total well depth below`land surface 25 {tt,) 24a. For All 'Vlkihs: Submit this form %ithin 30 bays of complaion of well
Formsrfriplrwrtlslisr all deprlarlldoi'ren;trample-.r@3ft[l'atkf'l@l(' ) Construction to thc following:
10.Static water feed below top of casing: (ity) Division of Water Reswu r•ra'4,Information Processing Unit,
if xarter 1~1 Is mrwtr rrmstng,ase^+ 1617 Mail Ser iec Center,Raleigh,NC 27699-1617
!i.Bnrcholc diameter.2.25 (in.) tab•EgE 101M19A Welis ONLY: tr addition to stumding the fort to the addrm in
24aabove. also submit a oopy of this form within z()days of completion of%sell
12.Well QonStrnction method' DPT cottstruction to the following: 1
(i.c.anger.%gar)•.cable.direct puck etc.),
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27649-1636
i$a 1Retd(gpm) Method of test: Zda For Water Snpgil&in�ictlon'Wells:
Also submit one copy of this form within 30 days of completion of
well constniction to the county hcaltil depaemneat of the cauly worm
I3a.Disinfection type: - _ _ Amount: -_ _ —. constructed.. i
Fonn GWA Ntorlb Camlina Departancnr of Emimnmctu aid Nanual Resounxs-Division of%ter Resdit Revised Atgtrst 2013