GW1-2022-07526_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2725-A 16 rL 25 rt• saprolite
ft. rt.
NC Well Contractor Certification Number y 4
ET t 15:OUTER CAS?1YG for multi-cased mells OR I:INI R(if Q` lkatile
FROM TO DIAMETER THICKNESS MATERIAL
,< 2 ft. ft. in.
Company Name
16:INNER CASING OR TUBING eiithermsl elosed400
2.Well Construction Permit#: •�n1 f f^L �u ' FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permit OVW ,Co&.r tP.;!$kt ante.etc.) 0 rL 110 ft- 14 'n Seh40 I PVC
3.Well Use(check well use): ft ft. in
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic 10 ft- 25 rt 4 '"' 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
1ndustriaUCommercial 13Residential Water Supply(shared) 18.'GRt)UT
Inn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring %Recovery 2.5 ft• 6 ft• neat cement pour
Injection Well:
Aquifer Recharge DGroundw•ater Remedistion 6 fit. $ rt. bentonite pour through augers
19.'SA18D/GRAVJ'rsP CK'ifa Ircatic ,.. .�, „_u r-n . ��a.ti _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODw
Aquifer Test DStormwater Drainage 8 rt 25 ft #2 silica sand pour through augers
Experimental Technology Subsidence Control ft• ft.
Geothermal(Closed Loop) 13Tracer Q:,DRILLI]�CrT1QG �ttaFi iidditibhBljhtets tfnetessar
Geothermal(Heating/CoolingFROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)Return) Other(explain under#21 Remarks) ft.
See Consultant's log
4.Date Well(s)Completed:6/9/2022 Well ID#RW 10 ft. ft.
5a.Well Location: ft. ft.
Charlotte Douglas Int'I Airport ft. ft,
Facility/Owner Name Facility ID#(if applicable) ft ft.
Airport Drive, Charlotte 28208
Physical Address,City,and Zip fit ft.
Mecklenburg z1.Izlt�far:xs; .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lao'long is sufficient) 22.Certification:
35 12 29.25 N 80 55 45.03 W 7/4; 7/8/2022
6.Is(are)the well(s)oX Permanent or Temporary Signature of Ce red Well Contractor ` Date
By signing dtis form,I hereby certify that tlue well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XDNo with 15ANCAC 02C.0100 or 15ANC.&-02C.0200 if'ell Conshuction 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 prmided to the well owner.
repair under 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 (-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C`,?00'and 2@1001 construction to the following:
10.Static water level below top of casing: 16.5 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10.2 5
(in)
24b, For Infection Wells: hr addition to sending the form to the address in 24a
Aug er 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 2 7699-1 63 6
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 to the county health department of the county
where constructed. f
Form G\V-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016