GW1-2022-07524_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.WATER ZO1�fkS n ::
FROM To DESCRIPTION
Well Contractor Name
2725—A +r $ `" V 16 ft• 25 ft• saprolite
li"� ft. ft.
NC Well Contractor Certification Number
ET 1 i5:OUTER CASING for multi cased wells 012 LINER if d heab'Ic as _
pl�r, i FROM TO DIAMETER THICKNESS MATERIAL
i Intl rt. ft. in.
Company Name
46:INNERCASINGC3R'TUBING. eotherinal-closed-too
2.Well Construction Permit##• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cousin'•State, Pariance.etc•.) 0 ft. 10 ft- 4 " Seh40 PVC
3.Well Use(check well use): ft. ft. in.
371SCREEN
Water Supply Well:
FROM TO DIAMETER',.SLOT SIZE I THICKNESS I MATERIAL
Agricultural [3MunicipaL'Public 10 rt 25 ft 4 in' 0.020 1 SCh40 JPVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. ini
hidustiial.'Commercial Residential Water Supply(shared) .18.:G120UT "
hri ation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. i
Monitoring %Recovery 2.5 ft- 6 ft• neat cement pour
Injection Well:
Aquifer Recharge Groundwater Remediation 6 ft. 8 ft. bentonite pour through augers
A'SAI)FD/GRAB' if
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage 8 ft. 25 ft- #2 silica sand pour through augers
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.,DR1LL]N6 T(3G 8i2ac7iadditioriil,4160ets if riecessli'
FROM TO DESCRIPTION color,hardness,soiVrock e, in size,etc.)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remark) ft. ft.
See Consultant's log
4.Date Well(s)Completed:6/21/2022 Well ID##RW 12 ft. ft. k
5a.'Weil Location:
Charlotte Douglas Intl Airport rt. ft,
FacilitylOw•ner Name Facility ID#(if applicable) ft. ft.
Airport Drive, Charlotte 28208 ft.
Physical Address,City,and Zip ft. ft.
Mecklenburg <214EAIMW,',,-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35 12 28.55 N 80 55 44.13 W 7/8/2022
4&
6.Is(are)the well(s) x Permanent or OTemporary Signamrn ofCcr ed Well Contractor Date
By signing this form,I hereby certiJc thl t the well(s)was(were)constnrcted in accordance
7.Is this a repair to an existing well: ®Yes or EJNo with 15A NCAC OK.0100 or 15A NCAC 02C.0200 dill Construction Standards and that a
I fthis is a repair,fill out known well constriction information and explain the natiov of the copy of this record has been pmrided to the well owner.
repair imder#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: 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-3@¢200'and 2@a 100) construction to the following:
10.Static water level below top of casing: 16 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For rniection Wells: fit addition to sending the form to the address in 24a
Auger & Air Rotary above. also submit one copy of this form within 30 days of completion of well
12.Well construction method:
oonstruction 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
I
i
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 t€ 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