GW1-2021-08037_Well Construction - GW1_20211122

WELL L CONSTRUCTION RECORD For rnenmi Use ONLY:
niv<ronncan W asod far single or multiple melts
1.Weil Contractor Information:
T4:c�*art
Brian Ewing FROM im I ors ""ON
4240 B
NC Well CoornaorCertifami.ionMamba t5.€1UMCASING ar Hltastdnrt AIt-I.11!tER S t?ex35
FROM I TO t TVNIF.TER TR KNTiSS htATERiA6
SAEDACCO inc 0 fL 26 IL 2.25" is. NA STEEL
CotiVoot Nano t6 t3R:7i1 tY rdstt a
FROM I TO I NAN1ETER I THICKNESS I MAnRIAL
2.Well C`nnstrntxion Permit k: R. ft. in,
1.W artlapi UmNe well fw mitt}lee.County,Starr;Variarwe,11*UM e:r.)
3.Well Use(check aril use): 113C N
Water SupAv Weil: FROM TO mAINRT6R StATT 5f7r T11t, NM MATMtAr.
OAgrscultu al DMunicipaD70 ie 26 ft. 30 R, 1.25" In, .004 NA STEEL
OGeothetmal(Henting/Cooling Suppiy) Olkesidentiat Water Supply(single) H. tt
DlndustriattCommeniai Oftesidentiat Water Supply(shared) #P t1tK31TT
FROM I To MATERM. E..MPLICEWRNT 7METtiOD&AMOIN
01eri tion ft. ft
Non-Water Supply Well: ft. ft.
MNIonitorin E)Rsv tnv
Injection We":
OAqu*r Recharge Wrounduuter Rcmediation 10.SANDIGRA LPAtSI[st
❑Aquifer StoTNgc aidRwA)NCR ❑Satinity Harrier rR M MATTSRtAt, RtitPr A . rTMr Tn n
R, R.
13 Aquifer Test OStommiticr Drainap:
R. A.
OExprrimcnfalTmhnology OSubsidevictCarefu3 �a'nl anc addiHoaai'iloeetsifieccassrt .
OGeothenital(Closed Loop) OTrracer FROM I TO DESMWFIOs"r:rirVn aiatrmea n err
❑Geothe n al(Hesfing2oli2j Rettim) OOthef(eWtn'under p21 Relmiksl 0 ft. 25 ft. FILL SILT AND SAND
25 ft. 30 ft SILT WET PWR
4.Date Well(s)Completed: 9-22-21 WellID04-04A
sa.Well Location. O �
Former Charlotte Army Missile Plant ft. (t.
Facility aatrcr Name FactlEhy ID#of lice) --
ft. ft.
1824 Statesville Avenue, Charlotte, NC, 28206 A. H
Pig=sicat Addwss Ciq-.and Zip 21 A 1A
Mecklenburg WATER SAMPLE W/SP-22 DJ1,1t N--U i iUN
County P$ntoIdtraifWtionNoS (PIN)
ft.Latitude and if ongitude in de�eslminutes/scco e=nds or decimal degr 22.Ccrtilication:
(if Veil fitW,otre I.Rtllong I,4 irdtie r:ra)
N W Bda.n-Ew*1.0&- >0/13/2U21.
Sigaamm ofctnified Well Contmctw Daic
6.is(are)thetyellts): OPermiment or OTemporaq g,•sigaink this farm.1 hereby ivel r-Thai the uwi4s7 nun fixrrri awarourred ire ativnftmee
idth I JA NCAC 027C.(ill)')Oe 1Sq NCAC UC.IJNIXs dell Consirwed nr Stuneitrtds area Chas a
7.Is this a repair to an this rg yell: E3Yes or MNO c vn�rhir rawtnxl Irae brew Psraritlyd srs sh[Hell novae►.
If rhls it a repair,fill imr knots a wrel eonirna orlan btfr7msadmr emd r xplah the nrtmre of Or
repair wnlrrrr21 rmarb secAm or ern du hmk of'rhis form. 23.Site diagram or addttion>al teed lletaiils:
You maw use tine hack of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details: You may also attach additional pages if necewr,-
For mrdrtlde irr/e*m or rarer-xtwwr in"Ph rr-eils ONLY infrh die some ronsfnwfim>you t nor C 111 I7"1 A , 11TC�[T(i'1f)TVC
sum rant form. �� f
9.Total rvt9t depth belon,land surface: 30 (ft.) 24a. For All Wells: Subunit this form n thin 30 days of completion of well
For l"14010"Its No all deluhs lfd*rmr lexample-3@20 ,dad7@+100) construction to the foltoning;
10.Static water Intl below top of c"nw (i},) Division of Water Resources.Inforimation Processing Unit,
If wwtr level is attune eosir4#.use"•" 1617 Mail yen ice Center,ttsrrW0,NC 276"-1613
11.Borehole diameter:2.25° (in) 24b.Eqr Iniatign Wtills ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Weil constrnetion Mertitod: DPT construction to the following:
(Le.farW totael•rabic direct itrrsRctc:) Dhision of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY* 1636 Milt Service Center.Raltigh,'NC 276"-1636
I
13a Yidd 2.4c.For Water Suggtv&Init ction Wcits:
') 31�ir lhod of Also submit one copy of this form`Within 30 days of comlgetion of
13b.C13t9nfedina t Amount: well constriction to the county health department of the county whcm
constituted.
Form GW,t Nonh Carotins Dgwturat of Emironnt¢tu and Nantral Resontccs-Division of Wateraesotraes tte0sed AigU12 0