GW1-2021-08034_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For rttsrtwiUscONLY:
This=farincan be osod fat sin k er mWtipk wells
1.Well Contractor information:
14,tirA1ER 20Ni S
Brian Erring FROM Tp asciCRrPttOe
Welt Contradot Name
4240 B R. 2
NC Well Contimor Certi6®tDn Number 15.011M CA5rNG Oar nuhkawdwslt OR tXWR N&noscab
FROM TO DtAWMER TRWKN M MATERIAL
SAEDACCO Inc 0 R, 31 (L 2.25" Ia. NA STEEL
CovWaa,Name 18.1XM CAS G 01t TUBING ►ergnfd ced400pl
FROM I TO I DIAMETE TMCKNESS MATT=•IIAL
L Well Construction Permit# R. ft. hL
Lis$all rrpplirahlr writ prmritz it e.Cmmrh,Sou,Variance,Ilysrliort rtr.) R.
3.Well Use(ehecit well use): 17.SCttELN
Water Supply Well: FROM To ptAMETFiR : sT SI TRICxness MATMIA1.
OAgrkuharl( L71vtMicip3l/Pttblic 31 R. 35 ft. 1.25° im .004 NA STEEL
DGeothctmal(Ileating)Cooting Supply) ❑Residential Water Suppb•(singic) R
t;Rt)OT is
01ndustrialiComtlxrcial 011csiderroal Water Supph•(sfmmd) tAs
FROM TO MATEm" EhtF1ACE&NT METROD A AMOITNT
ObTi tion R. IL
Non-Water Supply Well:
tt. R.
m1Nonitori ❑Recove
Injection well: R. (L
DAquifcrRecharge 00mundivaterRemodiation ttt. D/G VfaLPA. iphk
M re. MATPRtAr, rmpi Atintivri", on
C3AquifcrStomSc and Rccoveny ❑SalinityBarricr fi. A.
OAquifer Tcst ❑Stommatcr Drainage ft. ft.
OExpelittncnial Tcehnolog 0subsidcrice Control 30 0 RUMNti LOG(sot adBifl oat ►ctasifaecet�Ta
OGaothertal(Closed.Loop) OTtacer FROM To DRse W"ON tvhfth rsnta wrocat ao
1343eOthermal(Heati1 li Return) 130thef( under921 Renati 0 R. 10 fL FILL SILT AND SAND
25 R. 35 R. SILT WET PWR
4.Date Well(s)Completed: 10-5-21 WellIDAGW-26 R. (L
St.Well Location:
Former Charlotte Army Missile Plant
Facilih'l0VvtrrNarm Facitih iDll0fspplWblcl
R. R.
1824 Statesville Avenue, Charlotte, NC, 28206
Plgsieal Address-Cite.ass Zip 23.RC—M t21tS
Mecklenburg
WATER SAMPLE W/SP-22 ;
C-oh, Pamel tdmtiriuttion No,(PIN)
5b,latitude and t,ongttude in degrees/mimrtes/sceonds or decimal dogrcm 22.Certifkabion:
(If welt kw,sae Mons it;snhicietd)
N W Bria.n'.EW* 10/13/2021
Sinn[of eediscu Well Contractor - Daly
6.is(are)thewell(s): C3PCimanent or ETemporary Bti,signink Air fame.I hereby tern;/}thrar the well(s)wax(coral ewwoueted in arasardrarrr
with I5A NCAC 02C.01W ar 154 NCAC(r.C.02M 1)rq Camsov,�tion Standards and that a
7.Is this a repair to on existing well: OYes or MNn rvepp of dth reward hax hrrn prerAW to the nrll turner.
If obit it a repair,fill raw tnown well eowtwyfon brtformathm and r.g4ahr Aw swear of the
repair cmdrr#21 rmarkrseesian or ran the hark of thix farm 23.Site diaprom or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells eotvtructed: 1 construction details. You may also attach additional pages ifnecessavy.
f`ar mrririple igjt"M 0e aan-avner sapplt,avth ONLY tilde rho-rant eoasrracd0m,von eaa CtB11ti1TAL INST[C170NC
svbmif mn farm. -
9.Total welt depth below land surface 35 {ft.) Z4a. Fier All Wells: Submit this fart within 30 drn,s of completion of well
farmsdriple evils list oYdMhj lf+1Wrent(examp1e-3@2M'ead 2@101') construction to the fnitoning:
10.Statle water level below top of essing: (00 Division of Water Resources,information Processing Unit.
l/waser level is above ewliag,rite"+" 1617 Mail Service Center.Raleigh.NC 27699-1617
11.Borehole diameter:2.25^ 246.For tnfeetion Wells ONLY: in addition to sending the form to the address in
24a above. also submit a copy of this form within 30 dais of completion of well
t2.We1I comtruetlon method: DPT construction to the following:
(i.e.auger.rotary.cable.discs push ctc.)
nhislon of Water RtsoDnccs.Underground Injection Control Ptogsam,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Rale){:h.NC 376"-1636
13s.Yield 24c.For Water Sue &inj_ection wells:
(gym) Method of test Also submit one coin of this fonn�mithin 30 da}sof completion of
131).Disibfectinn type: Amount: well consiniction to the county heahh dcpcartmew of the cmudy when:
constructed,
Farm Gut-1 Non h Camllm Dgnrurcm of Envimmuerx and Nanrrrt Rcwumes-Dkisloa of Water Resources Revisal At{gust 20I3