GW1-2022-07521_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.VFATER7ANES'
Well Contractor Name FROM TO DESCRIPTION
2725-A 15 ft 30 et. saprolite
NC Well Contractor Certification Numbetly,� p t 1S:,0VTER CASING(for itia •e lttased wells OR UNER if a` l icab7W
ETtt �' Try* ^(1�� FROM TO DIAMETER THICKNESS MATERIAL
/l fL ft. in.
Company Name
U 16.1NNER CASING:OR TUBING` rothermal closed-loa
2.Well Construction Permit# ;n�f'^'` FROM TO DIAMETER THICKNESS 1 MATERIAL
List all applicable well construction pe te.UIC,f JFIi( t te, f/ar ante.etc.) 0 ft. 15 ft' 4 to Sc PVC
3.Well Use(check well use): fL ft. in
Water Supply Well: 47.,
FROM TO DIAMETER SLOT SIZE THICKNESS T MATERIAL
Agricultural [3MunicipaVPublic 15 ft- 30 rt• 4 in'' 1 0.020 1 Sch40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
htdusttial/Commetcial Residential Water Supply(shared) :fRZOLFT
In'i ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring %Recovery 2•5 ft- 11 ft• neat cement pour
Injection Well:
Aquifer Recharge []Groundwater 11 rt. 13 ft. bentOnite pour through augers
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 13 fL 30 ft- #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING I OG`atl'ach addttio6h hens�f'"cessa" `
FROM TO DESCRIPTION color,hardness,soil/rock e,gmin size,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) ft. ft.
See Consultant's log
4.Date Well(s)Completed:6/1 312022 Well ID#RW-15
ft. ft.
5a.Well Location:
Charlotte Douglas Int'l Airport
Facility/Owner Name Facility lD#(if applicable) ft. ft.
Airport Drive, Charlotte 28208
Physical Address,City,and Zip
fL ft.
Mecklenburg 21.12FNfAT2TtS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35 12 27.68 N 80 55 43.85 W, 7/8/2022
6.Is(are)the well(s)Ox Permanent or 13Temporary SiL,,aturc of Ceelied Well Contractor i Date
By signing thisfornr, I hereby cerafiv that the uell(s)was(were)constricted in accordance
7.Is this a repair to an existing well: 13Yes or X)No with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Cahsbntction Stwhdardr and that a
If this is a repair,fill out known well constntcfton information and explain tie nature of the copy of this record has been pnmided to the well owner.
repair under 421 remarks section or on the back of this font.
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-I 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: 30 (th) 24a• For All Wells: Submit this form within 30 days of completion of well
Formultiple wells listall depths ifaVj rent(example-3@200'and 2@100) construction to the following:
10.Static water level below to of casing: 15.5 R
p g: ( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
25
11.Borehole diameter: 10. (in.) 24b. For Infection Wells: hi 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& Injection 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 io 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