GW1-2021-07988_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For rraenmi UscONLY:
This fannctm be used to single ar mania*dells
1.Wdl'Contractor Information:
14 ti'A'1Blt"rO. ,.r.
Brian Ewiag FROM I TO Des Rlr ON
U141 ContractorNar+>c
4240 B
NC Arell Commor Ceti if=tion Number S,i1[ii1' ft+7 (tariftutri tTRtdNY.it g " ttatb
FROM I TO K4W Ttt1C'KNM MAnIUAL
SAEDACCO Inc 0 (L 37 fL 2.25° M. NA STEEL
CoRr u "tYsme 76 G"Qlt MING tgwtktaaad� t
FROM TO L DGIMETER TrnCKNE94 MAMR1AL
2,Well construction Permit# R G.
List all appfitvsbddr,emit pe-Wis fir.Cauntr,state:Vadowe,1*Xdar1 rtr.) ft. h ear
3.Writ Use(check wellnsc), ti SCRT�fi
Water Supply WdL FROM TO ArAJMVTRR 5t 07 stir ttittycrrrssI MAtPRtAl.
OAgrivm haral CSMnnicipavmlic 37 R. 41 ft. 1.25° la 004 NA STEEL
DGeothemtat(HeatingiCooling Supply) OResidential Water Supply(single) ti ter in
t tnilltitriat/Gontnrerc ai 01tesideriftl Water Supply,(spitted) FROM
FROM I To � stATeatnr. RMr1.AcEsrFXr Murree 6 wMouvr
❑irri tion ft. (4
Non-Water Supply Well: � ft.
mmonitorhts 131tecawry
ill on Well:
[Aguilar Recharge OGroundwatc►i cutediation 19:5" ox L r
FrOM TO MATF.R41m: RM1*mcA CyTYNF7tIt4t!
DAtluiter Storage and Rcw%vTy ❑Salinity Sarricr ft, 0.
❑Agpifcr Test DStomm-ater Dminngo ft. it.
Dt xpctimcnint Technology DSrtbsid=c Control
2tl.�D attscti�dallflanWiet++retsifti�eccesa
DGeothemmai(Closed Loop) Mraeet FROM To DF,5CR1Vr1ON ire ta.t
DGeotherrnat(Reati bole Return) DOther(eqftifivnder#21 Remarks) 0 R. 25 h. FILL SILT AND SAND
25 ft. 41 (L SILT WET P➢RR
4.Date**Vep(s)Completed- 9-21-21 WdlID#Glr-10A
Sa.Well location: n ry
Former Charlotte Army Missile Plant n tt. �
FacililyAXk,rerNow Facility IV#(if Wplicabte)
R. etc
1824 Statesville Avenue, Charlotte, NC, 28206 ft. ft.
Pk-Aml Address.ON.and Zip 2t.R" ARtGS
Mecklenburg WATER SAMPLE N/SP-22 MVP KUliON
Cat My Paled ldemiri Hots No,(PIN)
Sh.LAtitadc and l onkritode in deg=0minutcslsecrmds or decimal degrem. 22.Certification:
(ninth&M,aft 1rl,70rrg it s+durkre)
N W 8-dan EY i g.1- 10/13/2021
Sigrestax ofCeollied Well Coturact'i DW
6.1s(are)the%vehi(s): EVermaneirt or ZTemporary 4 svgnkx mils frrrnr:I hrmby can t6 rhar the srl4sl was f*m)ermrtnwied in acsnrrtanre
with 13.i NCAC 02 ,010h or 15.4 hrCAC V.1�.02M tvru Coresrrrtrdon Standards and rlini o
7.Is this a repair to in existing well: Mes or M Copy a thdr errand 1:rts dr err prtmrdrd to rder nvlt mere.
Ijrhds Js o rrpair,ja11 imstsurisva cull(•arurrrrrrrftrn knfan.arkviaW cg4oiir do,aortae of the
repair under#d 1 remarks serfion nr an the beset aj`thds form. 23.Site diagram or additional well detaiha:
You may use time bw,of this page to pro%ide additional well site details or well
S.Number of veils constructed. 1 construction detain, You may also attach additional pages if necessary.
For mafrif*MjecrMn or ormi-4,mere sappkr sells ONLY wi4i the sane ronafnwtdwr,Vt*can
xUbaft4mfow S R t't'TA[ MMOUMS
9.Total well depth below land surface 41 (it.) 24a. For All Weiis Submit this forth within 30 duffs of completion of nett
For matlrdplr sells 1liroll deprh.y ffdorrrrr(rsua fr-it 2aRm'mrtd 2k%_/ _ i etmstnrCti4n to the fol loving;
10.Static water level below tap of casitmg: ((k,) Division of Water Resources,tnformat Ion.Processing UnIL
1f reerirr kf ej h SkWe rrdfn.Nr sue"4' 1617 NUH Scsviec Center.Ratelgh.?WC 276"-1617
11.Botrhemb duweeter:2.25° 010 24b.For iliklUar Wells ONLY: tit addition to sending the form to the address in
24a abm e. also submit a copy of this form within 30 dams of completion of well
12.Well constructlon method: DPT construction to time lbiiouing,
fix,sax.rater..c dbiq direct push etc-)
Dilftlon of Water Resaaires,Underground Injection Control Ptmgntn.
FOR WATER SUPPLY WELLS ONLY: 1636 M&H Service Center.Raters.NC 276"4636
24c.For Water Supj tj&Injection�ctls:
iJx Yield(j�tm) Method of test: Also submit one coff of thus form'riithin 30 days of completion of
13b.Disinfection h1w. Amount: xcll construction to the ctnmty health department of the courtly,where
constructed.
Ferro GtY-i Nonb Carolina Rc%1W At06t2013
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