GW1-2021-08033_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For ltsrmal Use ONLY:
This-formcan be umd for Sir&or mwliylc%wus
1.Well Contractor Information:
Ti1.WA'✓f 8R ZO'NICS
Brian Ewing FROM TO DrSCRtMON
w'cltCmthat�rName R. ft. �
4240 B
NC Well CordadarCenifxmtion Nuribe r 1S1011 ,R CASING oreentt n' I,TIYl7t [fir tieiMk'
FROM TO TUMETBR THICK"M MATERIAL
SAEDACCO Inc 0 fL 26 (L 2.25"11 ia. NA STEEL
Cal*-dly Rime 96. CAM 01t,MRING It"'"►emittioJosid
FROM TO DtANIETER. THIC&NKSS MATERIAL
2.Well Construction Permit lP: rL tt- to
Dirt aB applirum.-ava perrelts t i_e..Counh,State.variawe,Irljereat fir.)
R. fL tas.
3.Well Use(check well use): 17;SCR6Tc11 -
Witter Supply Well: K3"O
D14%tETrR st SiF.E TTr1CTCtitC55 MATRRtA:1.
DAgrscultural 0municipallPublic R 1.25" irb' 004 NA STEEL
OC*OthcnWl(HeatingJCooling Supply) [!Residential Water Supply(shiigle)❑1ndustrial(Commetcial 01tesidential Water Sappy(shared) MATERUL EMPLACEMLVTMERiOD&AUJMO❑trri LionNon-Water Supply Well:mmonitorin ❑Rccoirin eon Well:QAquiferRccharge OC3mundnnterRcmediation L A f` icahlr
❑Aquifer Slomgc and Recovery QSalinity Barrier PROM TO
rL INATRRIAL PMPt
rt.
❑Aquifer Tcst ❑StommatcrDminngc R ft.
❑r:xperimcntal Technology 0Subsidcnee Control 1p;DRtGUKG LOCI,
atttueli as]dldontu i'alrMs if tteceasa
❑Geothennal(Closed Loop) ❑Tracer FROM TO ORKIUMONi tsbr.MAr/pon NDW#Wktype, detM"M
❑Geothermal(Neatin Cooli Return) ❑(Utter( lain tinder#21.Rentaft) 0 tL 10 rL FILL SILT SAND
10 fL 15 ft. SILTY SAND
4.DatCR'cli(s)Contpletcd: 10-29-21 Wrdli(n1tSSW-GW-10 15 rL 30 (L MOIST TO WET SILTY SAND
Ss.Well Landon: �
Former Charlotte Army Missile Plant rl. tL
Facilitymn nor Name F9c1Mh,1DX(if sVp1k4iblc)
ft. rt.
1824 Statesville Avenue, Charlotte, NC, 28206 h D
PksiW AMmsi.City-and Zip 2t.11E: ARKS
Mecklenburg SP-22 WATER SAMPLE.
Caattly Parcel ldeatifieal)onNo,(PIN)
4b.iAtitadc And Longitude in degreWminuteslseconds or decimal degre's: 22.Certification:
(If utp(nd,om tat,laM Is sidrrcteat)
.Ew,N W Bran i.ng. ... 11,2,2021 �,�
Signatotc of Certified Well Cotittactor flatc
6.is(are)the well(s): aPermanettt or ETemporary A),hewing r b farm,i Aerrin•ern#(-than the uwJ1(.ri war("rr)t anstna•ted Staetwrdmry
w1A 15A NCAC 02C.010)or 1 SA XCAC 02C MOO n efi Coasrnsr-vion Standards and r1i®t tr
7.Is this a repair town cxtsdng/yell: OVes or ZNa copyofrhi,nvord bps been prertrirrd tithe mNlpwner.
ijrhis it a repair,fill fail4nvnvi wart!t~nwrion 14um arkm mW erptain dw norare of aw
repair tender$21 rernarir sertfan or on do ba-k of this farm. 23.Site diagramor 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 eonstmetion details: You may also attaeh additional pages if tmxssanv:
Far nra1t1p1t Rrjeerhar or unit-%wer simph arlls ONLY MM the snore catrafrarHan,wwr t.ta
sabout me form. S lRh i4TAL MS'l lt^9'TONS
9.Total well depth below land surface 30 (t:,) 24a. For A►t Wells: Submit this form within 30 dins of completion of well
for swldple wrlis liar all Oepht ifdtffererrt(eraMpfe-3@2D0'and 2e100 construction to the following;
id.Static water Invi below top of casbtg: ((t,) Dhision of Water Resourrttss,formation Processing Unit,
if iswer level tr abater eosdag,ate"+" 1617 Alail Senice Center,Raleigh.N% C 27699-1617
11.13orrrhnM diameter 2.25 a (in.) tab.For 1nleedan I=ONLY: In addition to sending the form to the addnw in
24a above. also submit a copy of this farm within 30 days of completion of well
IL Well construc ton method: DPT construction to the following:
(Co.auger:rosary.cable.dines posh cic:)
fthlon of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen'ice Center,Raleigh,NC 27699-1636
13a.Yidd(gpm) Method of test: 24c.For Water Suppir,&lNocthtn Weth
Also submit one copy of this farm within 30 days of completion of
13b.Disinfection type: Amount: xx-cll construction to the county health ileintrtrtuetu of the ccRlMy svhetc
constructed. i
FannG%r-1 worth Carolina Dopanincro of Emimiuma and Nannal Resomms-D-wision of Water R" ftn,6cd A N113