GW1-2021-07987_Well Construction - GW1_20211122

WELL CONSTRUCTION RIECORD For trftrnal Use ONLY:
'Mis:farm can be used for aingk Of Multiple nIells
1.Well Contractor Information:
t t.WAT94 ZONES'
Brian Ewing FROM TO DiiS(RtPttO%
Weil CttntracW Nrmc R. tt.
4240 B h. R f
NC Well Cormwor Certifrm ion Number 15.OU'l CAStNOWerrraifliriaved w� Oil timilda l)eable)
FROM To DIAMETER TIt MNFSS AIATFRIAI.
SABDACCO Inc 0 (L 44 tL 2.25" It. NA STEEL
Comprn y Name I&INMM CASING OR TUBOW 49#QlkV=A1 ebtmed011
FR M TO DLAMETRR- TBiMINESS MATERIAL
2.Well Grnstmcdon Permit N: R ft. `12L
list all applicable uarll pertain(i.e.Cenrnh'.Starr,Variance,1flW of etr..)
ac
3.Well Use(check well else): t?iS
Water Supply Wdh iaOM TO DiAMRTRR St. S11W, I MATRRiAL
CIAgricuttural ClMunicipali tlic 44 R. 48 R, 1.25" ia. .004 NA STEEL
DGeothematl(Heatinpr'Cooling Supply) OResidential Water Supply(single) R. (L in
Clindustrial/Cor ilmial DResidcuttat Water SappA•(stlared) FROM I TO MATERIAL EMPLACEMENT METROD fi AMDBhii
ClIrrigation R IL
lion Neater Supply Well: FL
mMonitorin ❑Rcco�
in c otr eU: 4,
0 Aquifer Recharge OGroundvvvcrRcowdiation 110.SAND VELPARMIC911014
OAquiFer Storage and Recovery ❑Salinity Saltier FROM R, iro ft. MATRRIAI. KMPiA- rF.\T MFTNoD
❑Aquifer Test OStorinwatcrDmiriagc
OEyrcrimcniai Tcchnology OSubsideriee Control
BOMA"G LOG mtkM afldltionel Iitcls N a:eeacsa
OGeolhermal(Closed Loop) oTracer To DISCRtMON rabr,lirMaew tQamxa 6*r'b'tkel
❑Goothemral(Heati r7Cooli Return) 130d r(explain under 021 Remarks) 25 (L FILL SILT AND SAND
48 R. SILT WET PWR
3.Date Wc[t(s)Completed: 9-22-21 Well mAGW-08A
f4
5n.Well Location: (LFormer Charlotte Army Missile Plant R.
Facilily,DncrNarae Facilils lD#(if applicable) R-1824 Statesville Avenue, Charlotte, NC, 28206 Physkul Address City.old Zip . IGS
Mecklenburg WATER SAMPLE W/SP-22 ;°i. I lJii.MIMING
Cotnay Psrtet Idetaifkallun No.(PIN)
5h.Latitude and Iongitudc in dcgnslminutc*/s ands or decimal dogrem 22 Certirmation:
(if.reli field,one tai•9atg is taftickot)
N W —Brian-Ewing.— 10/13/2021
Si4mtuic ofCentried Well Co maxtor Dasc
6.Is(are)the wcH(s): EVermanent or ZTemporary 6S,stigrdny thu farm.1 htre*r rern7y that Me%ruts)rma f oral ouminteled in actwrdtmve
u*h 154 NCAC 02C.01 M or 1,1A A'CAC.02C,02001Ye11 Constmtrion Sion0ards and that e
7.Is this a repair to an existing well: 0Yes or MNo ropy of Air retard hits hem pnnirkil ro slit aril a rrer.
lfA4 is n remir,fill tmr kwonw null rortsttu r*im it)fem*rkw and espfahr the turtere of rho
"Imir under N21 reworks sn-a`on or an the hark of thin farm. 23.Site diagram or additional well defalls:
You map use the back of this page to provide additional%tell site details or well
8.Number of wells constructed: 1 construction details. You inky also attach additional pages if nece4saty.
For multiple Ittlmikvi or nrHi-meter supply uw1h 01M w1rh rite Same wnserartion,yott ism
Avbimit one form. suaminALLNS1" CTIQNS
9.Total well depth helMr land surface: 48 (R,) 24a. For All Wells: Submit this form mithin 30 days of completion of well
Forsatldple wells list off ritprhYtfdlfttrrtnt(trtmtpft-J c^09`and2@10n') construction to the following;
10.Static water level below top ofeasiag: (D,) Rhimlon of Water Resourcm Information Processing Unit,
If want level b above,n7slop east"a. 1617 Mail Service Center.Raleigh.SW 27699-1617
11.Bomhntc diameter:2.25" (in) 24b.For InjUtflin Welts 01%Y: In addition to sending the form to the address in
24aabove. also submit a copy of this form within 30 days of completion of well
12.Well construction method. DPT construction to the following:
(i.e.auger.mum}.cable dirm push ctc.)
Division of Water Resentres.lTndel•gmDnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276994636
f
13a.Yield(Rpm) Method of test; 24c.For Water S pAy&Injathrn Wells:
Also submit one copy of this form'I within 30 days of completion of
13b.Disinfection type. Amounts well construction to the comfy heatth department of the county where
constructed.
Form GN'-1 Noith Catalina Ocpwtnremot Ernimnrocui and Natural Resources-Di%*loo of%Vaier Reknsm RCOMM AtOM2013