GW1-2021-08035_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD for fmcnal Use ONLY:
nis formcan be used for single or multiple melts
1.Well Contractor Informatlarr
;ti.it`At6it7X11'Sttr�'
Brian Ewing FROM TO I o IMON
%,Pelf Coatnxw Harm A. p.
4240 B ft. fL
NC Wdi Cotmuetor Cenificatmn Nunher I&Otl7' R CAASMMG 1or'truiM1- d VIVR OR 1d1tF.R if ZVOMM
FROM TO nTA!HF.TRR TNTC-KVM :MATERIAL
SAEDACCO Inc 0 n. 51 (L 2.25° Is. NA STEEL
Comp;tayNalrwe 16 IMM CASINGO11'1118M calk mo losed.l
FROM I TO ntAMRT6R. I TtrCKNE0 I MATLRIA4
2.Well Conante inn Permit 9: 0. ft. 6s.
List all applirWe weltpermts(de.County,Sane.Variaere.Ifferoa•1 etc) A. I t. in.
3.Well Use(cbeck well aae): t .Str'111CCN
WaterSupplp Weil: FROM TO AIAMVMR' StOTSIM IMICUNM I lMATFR1A1:
C)AgticlllturaliMtlnicipal/FltbliC 51 R. 55 R. 1.25° lm .004 NA STEEL
C Geothenual(HeatingCooling Supply) OResidential Water Supply(single) tt. ft. to
Dindustrial(Comtnerciai DResidentiai Water Supply(shared) 18 ©
FROM 170 MATERIAL DIPIACEMLNT MrMOD A AMOUNT
❑ini tion A. ft.
Non-Water Supply Well:
lSmotlitodn E311ccomly
Injection Well: ft. rL
ClAquiferRecharge 00roundwntcr11cowdiation 19.SANo Y1tLPAC1F kqb
OAqu fcr Storage and Recayver} ❑Salinity Hamer FR M MATPRUL FWPt.AM,.1rNT lMrr"On
ft. f1.
0AgaiferTesl OStomm-AWDminaac
❑i:q rimcntralToclmology DSldasidcr=Contro/ 0.DRILUNO Ohatia h additionsiskets Jfoecensrsl
❑Geothemml(Closed Loop) ❑Tracer PROM I TO n1SCRtMON fthr.bardom w1wruck ty PC,ffe"Araeer.►
aGeothennai(HeaGt rlCooli Return) 00ther(otphin under#2.1 Remarks) 0 f,. 25 h. FILL SILT AND SAND
25 R. 55 f. SILT WET PWR
4.Date Well(s)Completed: 9-24-21 Wd111)pGW-09A
(t. fl;
5a.Well Location: (L ft.
Former Charlotte Army Missile Plant fL fl. _
Facilit.00 ncr Name Facility]DO(if opplimble) P'r- u - _
fL fl. "
1824 Statesville Avenue, Charlotte, NC, 28206 ft. ft NOV 2 2
Pkskd Address.Cily.nod Zip -2L i'IltAXW4
Mecklenburg WATER SAMPLE W/SP-22
Cotrtsw Paretlldetairkatlon No,(NN) iTin,sQ,i0CESSI(2GUJ
Sb.Latitude and Longitude In dcgrecs/mimttes/seeonds or decimal degrecF. 22.Certification:
(If well fetid,one 1t 0owg is srdflcieto)
N W __Brian Ew.i n � - 10/13/2021
SismtumofCenified Well Convactor O31c
6.iS(are)the we0(s): i7Pertnancat or ZTemporary Ihv afgning thlt form.I hereby cemy�•that Me nwfA(s)°tar(!oral rwrtttrurted in acrardnnte
with 1 SA NCAC 02C.01 M or I SA NCAC 02C,02M Weil Cnnttrarr(nn Srandordt and that tr
7.Is this a repair to an existing well: Oyes or ZNo ropy of rhir rtrprd biwbe a provided to the null owner.
lfthlt'.to rerrtdr,,fil1 taart.knnrawa well ro`Wtucv mt Drforrnaldotr awl explain rite aurae of rite,
repair antler 821 remarh rerjion or on the bark affhit form. 23.Site diagram or additional well details:
You may use the back of this page t0 provide additional well site details or i ell
8.Number of wells constructed: 1 construction details. You tnap also adach additional pages if lixessary.
Fur mulNplt iR(ec°rMtt rN nfNl-w4treP suppJY MYllt O1YLY n'1fA the 61nne MftSn7rellon,yrrt+ran
s ANn t one form. SUBMITTAL INSTUCC10NC
9.Total ail depth be on land surface: 55 (t1.) 24a. For A@ Wells: Submit this form within 30 days of completion of well
For nrtthWe nulls list all depths(f d*rent aka(2@ 101r) construction to the following:
10.Static water level below top of easing: (D,) Division of Water Resources,Information Processing Unit.
tf water lever is arwte oa11N¢.rate"+" 1617 hlail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter:2.2 5° (fa) 24b.For iniectlon Walks ONLY: in addition to sending the farm to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well rnwstrttetion method: DPT construction to the following:
(i.e.wqw.towrr,cable.ditect push etc.)
Division of Water Rem roca.Underground fnjeetion Control Program.
FOR WATER SUPPLY{;ELLS ONLY: 1636 Mall Service Center.Ralelgbt NC 27699-1636
13&Yield 2�te.For Water Up&cot ink hen Wells:
(gpm) d►ledlod of test Also submit one cope of this fonn�sithin 30 days of completion of
13h.Disinfection IM,.- Amount: _ well construction to the county hcaltih department of the county where
constricted.
Fonn 6%1-t Mtah Catalina DgxiRmcat of F-mirunntcra and NnnaW Rcsotirms-Division of Waim Res&j l5 Revised?lwgust 2013