GW1-2022-07523_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name ,r,,,,: i y�. FROM TO DESCRIPTION
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NC Well Contractor Certification Number 1 202�
p�,�j ! L 15.'Oi7TERCASING oriniiltitased`syells ORIIAFR(ita' tcable
ETu� FROM TO DIAMETER THICKNESS MATERIAL
_ r•.r:� ft. ft. in.
Company Name tt1tC'�P"� +��1'ky�
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2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable)ell construction permits(i.e.UIC,County,State, Pariance.etc.) 0 ft 10 ft- 4 'n Sch40 PVC
3.Well Use(check well use): ft ft in
Water Supply Well: 17rSC12EFPT . _ .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipatPubli° 10 ft. 25 ft 4 iRI 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
h,dustrial/Commercial 13Residential Water Supply(shared) GROi3T:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I. ft.
Monitoring %Recovery 2.5 ft 6 ft. neat cement pour
Well:Injection W
Aquion Well: [3Groundwater Remediation 6 ft. 8 ft bentonite pour through augers
19:•SAS»iGRASE_1371�ICa ifs licnblc �.. t s"� a'az 1� �,rF<:�
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwwater Drainage 8 ft• 25 ft• #2 silica Sand pour through augers
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer .20.rDR11d INGIa0 atta"2h ndddioniil'sheets"ifi ecessa
FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) r3Other(explain under 421 Remarks)) it. ft.
See Consultant's log
4.Date Well(s)Completed:6/22/2022 Wen ID#RW 13 ft e.
ft ft.
in.'Well Location:
Charlotte Douglas Int'I Airport
Facility/Owner Name Facility IDII(if applicable) ft ft.
Airport Drive, Charlotte 28208 it. .
Physical Address,City,and Zip ft ft.
Mecklenburg =21:7ENrA1t>ss. -77
County ParcelIdentiticationNo.(PIN) Well vaults te be by anetheF eeAtffleteF.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22.Certification:
35 12 28.92 N 80 55 43.55 «
j 7/8/2022
6.Is(are)the weii(s) x Permanent or 13Temporrry SiLnatuie offer ed Well Contractor Date
By signing this form,1 hereby cerfijy that the w•ell(s)was(were)constnreted in accordance
7.Is this a repair to an existing well: DYes or XONo with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C.0200[Till Construction Standards and that a
1f this is a repair,full out known well construction information and explain the nature of the copy of this record has been prm,ided to ithe well owner.
repair tmder 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 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: 25 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30W 00'and 2C2a 100) construction to the following:
10.Static water level below top of casing: 1 1 (ftJ 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: 8.25 (in.) 24b.For Infection Wells: h,addition to sending the form to the address in 24a
Au er & Air Rota above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: g 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& 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