GW1-2021-08029_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For ttrterml Use ONLY:
nis Win can be Used for single or multiple webs
1.Well Contractor Information:
IJ.WATER ZO tS
Brian Swing FROM TO I DFSCAIMIOY
Well Conimclor Narrse
4240 B R fL
NC Well Coratnetor Ccntturetion Number -l5.OUTFA CA141NG or tmwitkamd weft)011 fit'' `ikable
FROM I To PIA:HF,TER T"K NES3 MATERIAL
SAEDACCO Inc 0 R, 31 (L 2.25° is. NA STEEL
Cbflf fit pll(fault T CASING OR TUBING tgoitre1Y- ila5gd4
FROM TO I D1AMF.TER I TmCT.TPES4 MATERIAL
2.Well Oinstruction Permit i# R. ft. in,
lint all appfi(nblr well ppen"As(ps.County,Sk"O.ehriarere.lnfe Eva rtr.) R.
3.Well Usc(chcelc well asc): 11 S ItC1EN
Water Supply Wells FROM f0 111ANKT8R SUtftC17T; 7itICiCNYS5 MATRRIAt,
DAgtfculttnai Clmuncipanublic 31 R. 35 R, 1.25° In. .004 NA STEEL
DGeothetmal(HeatinglCooling Supply) 01tesidential WaterSuppl)'(single) R. fit is
GlndusftwComm=ial (3Rcsidential Water Suppy(slated) Ill.GROUT
TO MATEWAL EMPLACE:MENT'ME1MOD&AMOUNT
i7hri ion fit. (L
Note--Water Suppty Welt:
rt tt
®Mwtitorin ❑Roccoery
Tn on well: R.
DAquifcrliccharge DGrotntdwalcrRcmodintion t9.SAND R.1 LPA( Cite RuiA `
,FROM MATSRtAt. RMP1A .1BVT Mr?Hon
QAquilcr StomSc and Rccmticiy 0salinity Barrier Lw�L
R. R.
OAquifalcst ❑Stornmvcrbraitagc
Mxperimcntal'Technology ❑SubsidcrccControl
,UR AJNGLOG ttbctAdM o%*1 htatnif.
OGeothetnml(Closed Loop) 13Tn1CCT FROMI I To DFSCRtrft0l asbY.tetMnew.intat+ucti n rtr
Meoihennal(Heatin Cooli Rerum) 00dser(explain under 921 Remarks) o ft. 10 fit. FILL SILT AND SAND
25 R. 35 fL SILT WET PWR
4.Date Well(s)Completed: 10-6-21 ai dIID#GW-27 R. tL
5a.Well Location: A. (
Former Charlotte Army Missile Plant fit fit.
FacilityKhvncr Name Facility lok(or appitabic)
1824 Statesville Avenue, Charlotte, NC, 28206 fL ft.
Plnsical Address City.and Zip 11::1S11t
Mecklenburg WATER SAMPLE N/SP-22
Count) PaneO Idttaire=11on No.(PIN) !":'FORtii
Sb.Latitude and Longitude in ticpncsimimrtestuconds or decimal dqrocs: 22.Certif-tcatioo: !�
(U.,iil tkld,one taGlons Is sli ickni)
N W B.r1a,n Evr�ng. 10/13/2021
SianetatrofCeaifred Well Contractor Date
6.is(tire)the we0(s): 17Permanent or mTemporary 1i-signing iNs firrnm,l hrrrby errs h•that,thr wrlks)ems farm)Cowimried in breonkm e
pith 13A NCAC MAIM or 15A NCAC 02C.(21M WeU Consrracrims Srondartlm and that o
7,is this a repair to an Cxis(itrs;well: ®lwet or IMNb rape t?(rhpr nrnrd has trews pmrirkd to 0w aaRrmiter.
(f thk it a rrp Oir.fill not k»oaw4 kW1 r.•ortitrutifoo infomwfim and fspldiim dw warren of rhr
repmair wndeel2l remarks•.wrA n or no the haws of th)a form 23.She diagram or additional well details:
You may use the back of this page to provide additional well site details or Weil
8.Number of%vlb constructed: 1 coitstntction details. You tntry also attach additional pages if twessan•.
For nm•trilde b((errkwn or w m-were ngrpmly wells ONLi'biro rise some ronstrerrteut.yo+r em
subsoil one fours. SJBAIMAt.2i3RU['TiONC
9.Total well depth below land surface: 35 (ft.) 24a. For All.Wells: Submit gtis farm within 30&vs of completion of well
For rrmlt)pdr we14 list al)drprht ffdi{iPrew(exvMpfe-3@2ull'coup 2@100) construction to the following;
10.Static water level below top of casing: M) Division of Water Resmurces,Information Pnaceasinp,Unit,
lfnrottrr kVr1 h above Cdsfn use"+" 161.7 Mail Service Center,Raleigh,NC 27699-1617
fl.Borehole diameter 2.25° (io,) 24b.For in .ilt1L Wells ONLY: Ire addition to sending the form to like addim in
24aabove. also submit a copy of this form within 30 da)%of completion of well
t2.N%,di eoostrttctlon method: DPT construction to[Ise foliominl;.
(i.e.amtbm roam.cable,direct posh etc.)
Division of Water Resoun'ca,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 276"-1636
13a.1fidd(gpm) Method often: 14,--For Water Supply&tr`ot:ton Wcits:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection hpe Amount, well construction to the county hcalth dclmrrmeuu or the county where
constructed.
Fonn owl-1 Nonh Csmlum Delmocni off lions emu and Natural Resouretss-Dhision of Wmci Rt zuxes Rev used AtV0 201.1