GW1-2022-07512_Well Construction - GW1_20220811

-or.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14,WATER ZONES 7,7777777
Well Contractor Name FROM TO DESCRIPTION
2725-A 1" ' 22.5 ft 32 ft saprolite
Rt C 1�'
�•� ft. ft.
NC Well Contractor Certification Number - -OUTER OTIE {ifA' [cable)%
IET AUG 1 s20Z2 >;
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. IIL
Company Name l pr:'-Gwing urm
In ' t _-16,INNER CASIN4 OR TUBING eothermal closed-loo
►.at r
2.Well Construction Permit#:
�•'��� FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,Couna,State. I'ariance.etc.) 0 ft 17 ft. 4 ra Sch40 PVC
3.Well Use(check well use): fL ft. in.
Water Supply Well: -47.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaL'Public 17 ft, 32 rt• 4 HL 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• fL in.
hidusuial/Commercial Residential Water Supply(shared) 18.GROUT
Itri ation FROM TO MATERIAL J EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EIRecovery 2.5 ft. 13 ft. neat cement pour
Injection Well:
Aquifer Recharge Groundwater Remediatirnt 13 ft- 15 ft. bentonite pour through augers
19.SANDIGRA PACK.(i_
Aquifer Storage and Recovery' Salinity Barrier FROM TO iv
LATERIAL I EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage 15 ft- 32 ft. #2 silica sand pour through augers
Experimental Technology [ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILIdNGL(?G atiach`additiorial5hects ifnecesssir'
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heatin Coolie Return) Other(explain under#21 Remark) ft. ft.
p,/�' See Consultant's log
4.Date Well(s)Completed:6/7/2022 Well ID#R V V-5 ft. ft.
5a.Well Location: ft. ft.
Charlotte Douglas Int'I Airport ft. ft.
FacihtyiOw'ner Name Facility IDfl(if applicable) ft ft.
Airport Drive, Charlotte 28208 ft. ft.
Physical Address,City,and Zip ft ft.
Mecklenburg f.REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lab'long is sufficient) 22.Certification:
35 12 30.88 N 80 55 46.72 W
W-/;& / 7/8/2022
6.Is(are)the well(s)oX Permanent or OTemporary Siunaturc of cc rcd Well Contractor i Date
By signing ins fomh,1 hereby certih-that the well(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: ®Yes or q No with 15A NCAC 02C.0100 or 15.4 NC:AC 02C.0200 Well Construction Standards and that a
If this is a repair:fill out known well construction information and explain the nature of the copy of this record has been provided toithe well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled" SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijferent(example-3Cg1,00'and 2@a 100) construction to the following:
10.Static water level below to of casing:22.5
P (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 0.25 (in) o
24b.For Infection Wells: hi addition to sending the form to the address in..4a
12.Well construction method: g
Au er above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 29c.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016