GW1-2022-07513_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.VFATER7ANES"
Well Contractor Name FROM I TO I DESCRIPTION
2725-AEG 24.5 f' 33 ft.
saprolite
NC Well Contractor Certification Number E��
r�� y t /1�'^/ Is.Oi1TER CASING for ntiulti-casedweils OR-LiI�R{if;u' ltca¢le);�� �' ..
ETAU 1• Z s �"`� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name i,)Pry UnA
1iTfii7RtEk+' 16.I14NERCASiiVGOR UBIiVG` 'tothermnlelosed=lod'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UC Countts State. I'ariance.etc,) 0 ft. 18 ft- 4 ra Seh40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural C]MtmicipaUPublic 18 ft. 33 ft- 4 i" 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in
hndustrial/Commereial Residential Water Supply(shared) ,18.,GROUT,
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring %Recovery 2.5 ft• 14 ft- neat cement pour
Injection Well: 14 enton 16 b
it. ft. ite pour through augers
Aquifer Recharge DGroundwatcr Remediation
19.-SAND_/GRAVE_1 PACK ifa ltetible. t .:;_;x
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage 16 ft- 33 ft- #2 silica sand pour through augers
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer '20:DRrLL,1NG',.,G,attach htlddronilh9heets'ifiti"acessai . °:4'- .
FROM TO DESCRIPTION color,hardness,soiltrock type, rain size,etc..)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remaris) ft. ft.
See Consultant's log
4.Date Well(s)Completed:6/7/2022 Well ID#RW 4 ft. ft.
5a.Well Location: ft. ft.
Charlotte Douglas Int'I Airport ft. ft.
Facihty/Owner Name Facility[D#(if applicable) ft. ft.
Airport Drive, Charlotte 28208 ft. ft.
Physical-Address.City,and Zip ft. ft.
Mecklenburg 21:RI14aRKs - :, ' : " . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 12 30.52 N 80 55 46.45 W
7/8/2022
6.Is(are)the well(s) X Permanent or OTemporary Si_natuie ofCrf ,ed Well Contractor i Date
By signing this form,I hereby certify that the well(s)it-as(it-ere)constructed in accordance
7.Is this a repair to an existing well: DYes or XJ No with 15.4 NCAC 02C.0100 or I M NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the natime of time copy of this record has been provided to the well owner.
repair under#21 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 1 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: 33 (f�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptins if dr&rent(example-3@100'and 2@100) construction to the following:
10.Static water level below top of casing:24.5 (t7J Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10.25 (in.) 24b. For Infection Wells: hr addition to sending the form to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply& Infection 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. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016