GW1-2022-07525_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD (GW-1) For hitemal Use Only:
1.Well Contractor Information:
Mike Tynan 14.WATER zA
Ir _ a
Well Contractor Name '�`r6- 9 FROM TO I DESCRIPTION
15 ft 25 ft• saprolite
P. I2725-A I r, ' 2022 ft. ft.
J..Certification Number
ET lrltt%d t s�T�f`:a5i ,%ng Ural 15:'OUTER CASING We)for multi�ased;
NC Well Contractor Certi wells ORIdNER{if ii`'Tfc
MHO
FROM TO DIAMETER THICKNESS MATERIAL
t�•lr�y ft.
Company Name
16.IPiNER CASING OR TUBING.Qeotliermhl elosed-too " _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State, l"ariance.etc.) 0 ft, 10 it. 4 rn SCh40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SGIEEN
FROM 70 DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 10 ft. 25 ft- 4 rn• 0.020 SCh40 JPVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well:
I
Monitoring gRecovery 2.5 ft. 6 ft• neat cement pour
Injection Well:
Aquifer Recharge Groundwater Remediation 6 rt. g ft bentonite pour through augers
RAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3%ormwater Drainage 8 ft- 25 ft• #2 silica sand pour through augers
Experimental Technology 13Subsidence Control fL ft.
Geothermal(Closed Loop) 13Tracer 20.DRITTINGJACr"attacliaddit'ional'4heetsrCnecesstii ,. :.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remari ) FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.)
rt. ft See Consultant's log
4.Date Well(s)Completed:6/22/2022 Well ID#RW 11 rL ft. y
5a.well Location: ft. ft.
Charlotte Douglas InVI Airport
Facility/Owner Name Facility[D#(if applicable)
Airport Drive, Charlotte 28208 ft.
Physical Address,City,and Zip ft ft.
Mecklenburg z1..RARIcs
County Parcel Identification No.(PIN) Well vaults te be by anetheFeentF
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 12 29.55 N 80 55 44.16 W
�y�� /utuuz 7/8/2022
6.Is(are)the well(s)0X Permanent or OTemporary Signature of Cer' ed Well Contractor Date
By signing this font,I hereby certiiA that the rrell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or X)No with 15.4 NCAC 01C.0100 or 15.4 NC:Ar-02C.0200 Rill 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 to the well owner.
repair tinder 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
chilled' 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@I00) construction to the following:
10.Static water level below top of casing: 15 (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: 8'25 pp(in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
Ot
12.Well construction method: Auger Air Rotary 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 Mail Service Center,Raleigh,NC 2 7 699-1 63 6
13a.Yield(gpm) Method of test: 24c.For Water Supply& Iniection wells: in addition to sendine 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. r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016