GW1--03744_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For lrtcnalUsc•ONLY:
This form can be used for single or multiple wells
I.YVell.Coutrtctar Iirformation:
'14,I ATERZONES
Zach Thompson FROM TO DtICRIP'"ON
WcllCoritaaorNam ft. R.
4478A 2 fL
NC Well ComactorCenifxmionNumber M OUTER CASING ORLINM(ify0 rlca6k
FROM To DL4�tBTRn THWKNESS hIATERML
SAEDACCO Inc 0 ft. 1 33 ML 2" lu, SCH-40 I PVC
Coui p my Nante M INNER CASING OR TUBING eoiiermat elased-loop).
FROM I TO I DIMMETER I TRIMNESS HATERUL
2.Well Construction ftrmit N.:
Lug(diapf u abfr m$prrmits(i.e.Caunry.Stare,Varfarwe.Bjeceen sir...) rL im
3,Wclt Use(chccicweil use): t7:SCRSEN
WuterSuppk Welk FROM TO DrAMETF.R SLOTSIrt: THIMNM I THATMIAL'
OAg6culntral omunicipatlmlic 33 38 ft. ft. 2" in O10 SCH-40 PVC
Meothennat(HeatinlgZooting Supply} ®Residential tVater Supply(single) fL rL in,
OludustriaUConunercial ©Residential\Miter Supply(shared) MGRODTFROM AIATEREAL 1 E\Ie[,ACEFMThiEittODs'Ak100Nr
Obit alion 0 ft, 26 It. Portland Injection
Note-Water Supply Nell:
Monitoring bRccovcry R. ft
injection Well: ft. FL
Q Xquifcr Rccharge MAountimalcr Rcowdiation 19.SAND1GrtAVEL PACK(if t rlic;WO)`
'HOM TO MATRREAL I B51PIJkCFMK4THt7non
I7AgnifcrStoragc and Recuvcy 17SalinityHamer 31 R. 38 ft. Filter Sand #2.
❑AgnifcrTest QS1ortn%%a(cr IhaiinagC
R. ff.
Msperimcnlal Technology pSrthsidCnCC Control
26.'DRILLING:LOG(attach sdditionaal sheds ifheccsmn•t
OGeodteniuil(Closed Loop) ❑Tracer FROINr TO DESCRIPTION fcnbr.hardncE,wrYnlcktr 'n Aae.dtJ
OGeodnenual(HeatinglCoolineReturn) i10ther(explafit under 921Rettunks) 0 ft. 38 tL Silty Clay
38 fL rL Rock ,-;
4.Date%U(s)Ca"mpleted: 5/3/2023 Wetl iD#MW-35T
54.Wd1 Ltrcathin:
rL rt, ly 0 `, 2023
Former Charlotte Army Missile Plant fL fL
Facil1tpChsTrNawc Facility tDk(1fappiimble)
R. ft.
300 Camp Rd., Charlotte, NC, 28206 R fA
P113sicul Addmss.City.and Zip :2t:REM11AItftS
Mecklenburg Bentonite Seal from 26-31'
C4aal:' Parce]Wnlific.911on No,(PIN)
5b,,Latitude and Lcingitude in degrceslminutesAceonds or dcciriral ttcgrccs: 28 Certification:
(if%;*Il told,wbC I-Wom is gunIckrd)
35.2498 N -80.8375 W /fGf9yi1�0tZbili 5/7/2023
gratum of Certifted�l:ci�/Cantractor Daic
6.IS(art,)the well(s): EPernnancnt or OTemporary IN signing rbir.forw,I hereb}'certify'rhar Ar nril(s)wvs fwrml cararmcred in acrardance
u'fth I5A NOW 02C.0100 or I SA NOW M,tl2M trill Construakur Sfamiards and tixu a
7.Lv this a repair to an existing well: Mee or MNo cape 4#ik recoaf bras 8,'rn la>a *IM fa sAv ia-ti(Amer,
!f this'&o reF tlr,fill rwr k70N41 14'rrr fJ1U7trIC7laA fltfalYllf 71R1t trrJ(r t.eplahf frig 1117rore of ffle
repair amder 921;mnarkssrctiau orcvl the brxL oftfurfonm 23.Site diagram or additional well deraffim
You may use die back of this page to provide addiliotiat Weil site details or well
S.Nutnber of wells copstmeted: 1 construction details. You nab'also'atiaclt additional pages if necessary.
Formallriple irvecrhrm cN•ami-neurr supply wells 0JVLY udJi the samecoirstriwrimr,you can
srrb llf oar form. SURNILTTAL iNSTUCTIONS
9.Totat wL.11 depth Mow Land surface: 38 24a. For All %tells: Subunit this farm within 30 days of completion of v(�ell
For mulriole µ•ells 161 nNdaprbs lfd1'vrarlt(s1r0fMP&-3@2W(uul 2@ too) con54nicti0n to the foitotSing;
10.Statie water level below tap of casing: A) Diviisiun of Water Resources,InformationPrucessing Unit,
if nvrer h'gei 1,Above cvsslttn;usr"+" 1617 Mail Service Center,R deign,NC 2 7 699-16 17
11,Borchote diameter:6" (in,) 24b.Dr Gelecflon`4elhONLY. In addition to sending The forru to the address in
24aabove:also submit a copy of this roan.within 30 days of completion of%tell
12,Well coustrucdou method: Sonic Construction to the following:
(Le.a4ger.rosary,cables direct push etc.)
Division of`Pater Resourcm Underground Iujection Control Prograin,
FOR NVATER SUPPLY WELLS ONLY: i636 Moil Sen'ice Center,,Raleigh,NC 2 499.1636
l3rt Yield(gpm) hEcthod of test: 24c.For.Watcr Sub,ply&Injection Wells:
Also subrnit one oopF of this form within 30 days of completion of
131r.Disinfititiun type: Amount wctl construction to the cotmt� health dcpantnent of the Conrua%%hero
constaMcd.
Fortis GtL'-t Noah Carolina Dcpaitmem of Environmeta and Natural Resources—Division of Rraler RMatt+c s Revised August-V 13