GW1-2021-07989_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Iroerml Use ONLY:
The form can be owd for siogk or multiple welis
1.Well Contractor intortuation:
14,WA1VX ZONIS
Brian Ewing rR M TO ES D IRMO-4
W101 Comuctor Name ft.
ft.4240 B ft, 1
NC Wdl Cordr=or CcnifKm ion Numher It OUTFR CASMC# +u'sarfti•e*wd*eT OR IVNBR N:; tkabk
FROM TO DIAMETER TMCK"..SS MATERIAL.
SAEDACCO Inc 0 (L 40 h. 2.25- fi. NA STEEL
OnaVany Nam 16.IMMMA CA5ING LiR.TU81KG, Ikenrtmdi t
FROM 170 DWSUTRR Ttt1C70VCS3 MATERIAL
2,Well Construction Permit# (L I h.
flea all npptiruble wrtf permits fi_r.County,Stwo.t+arianrr.Irate rim ex.)
3.Wdl Use(clock well use): 11.SC,ittETi
Water Supply well: I�Nll-
I&GROUTLTo VANIRTER 51 S171, Tr1CW"SS MATERIAi,
OAgtictlituml OMunicipallPublic 44 ft. 1.25- IIL .004 NA STEEL
OGeothermal(HeatiugAC.00ling Supply) DResidential Water Supply(single)OIndllstriai/Commetcial ❑Residential Water Ste '"
ppf}`(s1rtlEd1 FROM I To nmATEatAL $.+srLACT;MENrM>;•tltonBAMotnvr
❑iari tion ft. (1.
Non-Water Supply Well:
(1. ft
Mmonhotin Oltccote
Injection Well: rl. iL
OAquifcr Rcchsrgr OGroundwater Remcdiation 14.S lCRAY L C!C t( Ieiiltte
OAgnifer Stomgeaid Recovery ❑Salinity Barrier Fa M m slArsatat. EMm A.,to rMrT n
R. (t.
OAgaifcr Test ❑StornmZtter Drainage
fr. ff.
❑E.xpcdmcntal Tuhnoiogs OSt"dcncc Control
10.03tu t1tl1LAG addltt"Skcdsif
❑Geothennal(Closed Loop) OTractr FROM 170 aRecRtrmox tour,harrdfim wcttmek opt.0tsift ea.
OG'othermmmal(Neati /CoolineReturn) 130dw(otplainunder#21Remat1cs) 0 (L 25 (L FILL SILT AND SAND
25 R. 44 ft SILT WET PIER
#.Date WeR(9)Completed: 9-21-21 Well ID#GW-12A
5a.Well Location: (L IL
Former Charlotte Army Missile Plant fl. I ft.
FacilitpDo-rrr Name Facility ID#(if applicable► 77 .-.
1824 Statesville Avenue, Charlotte, NC, 28206
Phs sical Address Croy.and Zip ;
Mecklenburg WATER SAMPLE W/SP-22
Ceuml parcel lderniriealion No,(PiN) DTVR SEC I ON
r,er .a,' J r Idl
5b.Latitude and Longitude in degrecs/minum/seconds or decimal degnccs: 2L Certification:
(Itaeil r'►eld,one 1ai,700p is srdriciasa)
> W Br an.Ealing. 10/13/202.1..
Signamn ofCenutkd W&Coi�acmr Doe
6.is(am)the weli(s): OPermanent or ETempor•ary By signing this form,f herefn-errtlfe Thai 1he ualNsl rats f werr)evmvtivered in a rordaner
ivirh 15A NCAC 02C.01W or 154 NCAC:02C,0200 Well Cottumfsion Standards and short a
7.Ls this a repair to in existing well: Oyes or MNo copy of thin record has hem prov1*4 to A r uril ounce
/f this it a repair,fill tmr know"well eonsitutWim fnfrmrwtkrn and trirtain Me nurart oJdrr
repair mader021 mwur"r.irriion or on the bark of this farm. 23.Site diagn an or additlot al well details:
You near•use the back of this page to pmiide addifionat well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if tmessairy.
For nuhfpte in,(ecthm an non-uvater supply,4,rUs ONLY uJrh the same ronsa artllaa,W*a can
submit anne farm. SURNIMAL INSTUC7TM
9.Total well:depth below°land surface:, 44 ((1.) 2aa. For All Welke Submit this form uiihin 30 days of completion of well
For mahlpk rrlis Hit all d"i if construction to the fol cming;
10.St*tte water level below top of casing (ft.) Division of Water Resources,Information Processing Unit.
lfnraire level is above caiintt tose"4' 1617 Itteil Service Center.Raleigh,NC 27699-1617
11.Borehole diameter:2.25- (iD) 24b.For inlrrtlon Welt_:ONLY: in addition to sending the form to the address in
24aabove. also subiuit a cMi of this foam within 10 days of completion of well
IL Well construction method: DPT construction 10 the following:
(i.e.anaer.rouq•.cabta dicta posh etc.)
Dhlsion of Water Resources.Underground Ittjectlon Control Program.
FOR WATER SG'PPLY NATLLS ONLY: 1636 Malt Service Center.Raleigh,NC 27699.1636
13a Yield(tgtm) Method of test.,
For Water.5up rlr•&injection�Vetb:
Also submit one copy of this form"within 10 da)sof completion of
13b.Disinfection tvpt: - Amount construction consction to the county hcajth department of the count}°wheat
consimctod,
Form Gun-1 North Carolina Dgwtm-m of Emimnvrn and Nntrual Rcsotmcs-Division of NratcrRdsoutes Revised AL%ust 201.1