GW1-2021-08025_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For larcnmi Use ONLY:
This form can be cued for single or multiple wells
1.Well ContractorInformation:
14.AMATERZON IS
Brian Roving FROM TO ar4cRipirlos
U'e11>Contrdoor Name
4240 H
R. R.
NC Well Cmdraetor Certification Nofuber 15L OUTER CASiNG nrdi-easedlhe Oitt lf` lkable
FROM TO arAMETER :t1AT6R1AL
SAEDACCO Inc 0 ft. 21 rL 2.25" .in. NA STEEL
rompocl�'Nante t I CAMG•ORTvB'1K e®thermalaJaccda
FROM I TO DL►;HETRR I T[fiVKN''ESS I MATERIAL
2.Well Constrac Linn Permit 0*
I.istall apptiaft-well prmtfts(ie.Cbtmh,Steen.Vnrianrr.I1lradorl err.) • R.
3.Well Use(check well#,k): zr_s
Water Supplyulellz FROM TO ArAMPTHR:_ StgTSt7l TInCUNISS I MATMIAL
C)Agf#cuttural DMunicipailPRbtic 21 R. 25 R. 1.25° ta', 004 NA STEEL
©Goothemml(Neating[C:ooling Supply) ®Residential WaterSuppfy(single) Rft.. In
Cljndusttr<tUGomntercia! C1Rtsidetlthtl WatorStrpph(shred) Is GROUT
FROM I TO DIATMUAL f1knP AC£MENT MEtHOD A AMOUNT
❑hri tion h. tL
Non-Water Supply Well:
MMonitor( lipteco'.Try
inject Dn ell: �• �
❑Aqu1(erRccharge ❑GtnunduvicrRemediation 19•SANO V LFAf:4C ,te
❑Aquifer Stontgc and Recoorry ❑Salinily 8aufier FR M t0 MATPRIAt, Fcupr.acrsrP![r M. r n
❑AO(er Test ❑Stormumter Drainage
❑>xperimenta)Tcchnoloa ❑Subsidcmic Control
RILLIlttiUOG aitszlraA�Nemalakrefsitaea ss
❑Geothert al(Closed Loop) ❑Trager FROM TO DI;SCRWno% t6br.604"ce snWrockt 6 etc
OGeothennal fflcathtKooling Return) ❑Other{ in Undet t)2!Rettniksl 0 R. 10 (L FILL SILT SAND
10 R. 15 R. SILTY SAND
s.Date Weil(s)Completed: 10-28-21 WdIID#SSW-GW-6 15 ft. 25 (L MOIST TO WET SILTY SAND
5a.Well Location: (L (L
Former Charlotte Army Missile Plant to fL ft
�A
facilNgAOrvncrName FacilityIDk(ifapp�icable) 4 -
1824 Statesville Avenue, Charlotte, NC, 28206 R, (G '
Physiw Addmss.City.and Zip 2LREMA
Mecklenburg SP-22 WATER SAMPLE. ,-0RR4 C hj
Casa Pared iMrnifrettlion No,fptlu) Util-
5b.latitude and Longitude In degreWminutc0seconds or Recimal degr ew 22.Certification:
fif utlt field,mce LUflong is stdn6cm)
W Brian .Ewin 11,2f2021 m
Signatureof6t41ott,0 1Camlr�wr g %.p W Date
6.is(are)the weli(s): OPermanent or ZTemporary &signing thft firr*o I herirh,cY 1(2 rYth�rhmlltr xrl x1 xrps°{rritrrl ctmrtnrrte+d Frt acrnndtmce
x irh 15A ATCAC l)1C,40100 Of 15A NCAC 42C:0200 tt e41 Comrra,-den Swndards and 4w:a
7.Is this a repair to an Lmisting well: ❑VCR or Mo rrpxo/rhdr rrconi/aas lq rp lrmrldrd rry rtic xrd)�wnter.
tf(fits is a repMr,fill out kwam well emor rcrhw+Infonwrfrm mrd e.vyroin dw narNre of the
repair wrder821 remarks eviian or on the hrwl ofthis jartn. 23.Site ding nm or additional well details:
You ntay use the baek of this page to proxfde additional well site details or well
8.number of wells constructed: 1 construction details. You uW also atlach additional pages:if necessary.
For mnlrtple 1 j*A m or nett-wirer AWy welts ONLY vildi efte same reasrrartion,yaa imv
u6nitme frtrm. SIAMLUAL INSTUCMNS
9.Total R ell depth below land surface: 25 (fL) 24a. For Ap Wells: Submit this fomr ttititin 30 days of completion of well
For muldpit,wylls lfsr alldepAy 1fdi�rmat(e enure-3e-209'aul 20low) construction to the fAming;
10.Static water level below top of casing: {j>t,) DivLglon of Water Resourva,Information Processing Unit,
11wa rr Mod is aborr casing,ntr"4 16117 Mail Sertiec Center,RaleW NC 2769t1-I417
11.Borehole diameter 2 25° (in.) 24b.For inkSgon Wettc ONLY. I addition to sending the form to the address in
24a above. also sulsnth a copy of this form within 30 days of completion of well
12.WCll ConShVetlon ntMbod' DPT construction to tit following:
(i.e.anger.nmm%cable.dieter push,eec:r
Dh•lslon of Water Re vas,Rem Underground tojectloa Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai)Service Center.Raleigh,NC 27699-1636
I
13a,1t'ield{gpm) Method of test: 24e.For Water Sue&&Injection Wells:
Also submit one copy of this farm '10thin 30 days of completion of
13h.:Disinfection type: Amount: .Neil construction to the county health department of the came•where
constructed. I
Farm GR'-1 Nonh Camlim Dzpsumrmof Emitommia mW Manual Rcsourocs-Division of Waicr Remu m Rcv-iwd AVM 2013