GW1-2021-07991_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For ltternnt Usa ONLY:
Tads farmcan be used for Mngk or tmdligk avils
1.Weil Contractor Information:
t.r.V►'ATIIR'TX1Pl
Brian Swing FROM TO I 00SCRIP'n05
Well Copt rapt Narm A. ft.
4240 B ft. fL
NC Well Commoor Certification Nmmbei 15.011TP.RCAS .G orPPwuftkvsrdbTeEi tx0mmankablei
FROM TO DIAMETER 7hic- RI5.S htATERIAI.
SASDACCO Inc 0 fL 31 fL 2.25" is. NA STEEL
Cam aly Name 16.IRMCASINO OR TUBING itettl"al dared 1
FROM I TO DfAri15HR THICKNESS MAITPJ"
2.Weir Construction Permit
list allapplirnblr well prnrits 0-r.C'wrntc,Stmr:Variaxr,llfeC69n elr.)
3.Weil Use(check well use):
Water Supply Well: vR at To nw.terFit ,STOTSIZIF. Trtrdl<mtzbs MATFRIM,
31 A. 35 M 1.25" ta. .004 NA STEEL
C1Agr�ulnita[ I�MtmicipalfFteblic
OGeothermal(HeatingACOOling Suppty) OResidential Water Suppf),(single) A' IL is
olndmastrial/Cornmercial DResidental WaterSnpph,(shared) I&GROar" .
FROM ITO MATERIAL EMPt.ACKMEVT 111E MOD A AMOUNT
O tni n A. rL
Non-Water Stipply Well: � (L
®Monhori E3R=(nvry
In j on Well: (L rt
13AquiferRecharge OGroundtratcrRemcdiation 1g.SANb (:PACKstplitfohlo
rROM MATPRIAl. KMPLA . Mc.TMy n n
OAquifer Storage and Rccavrty OSalinih•Harrier A. A.
OAquifcr Tcst OStornm-ter Dmira p ft. ft.
OEq rimental Technology 115rtbsiderrce Control 2A DRBAANG•LOG•Itaelr zdditla m dsk-els4r
OGeoibennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION w»r.Martnea tuirnmeli r+ rta
OGeothetmal(Heati > li Remm) 00dter 4explain under#21 Remarim 0 IL 25 A- FILL SILT AND SAND
25 tL 35 ft. SILT WET PAIR
4.Date Wet1(%)Completed: 9-24-21 Well IDgGtf-05A
A. (L
Sa.Well Location: A. fL
Former Charlotte Army Missile Plant ft. rt. P, =a,
Faclit))OUuner None Facitith 110(if appliwblc) d�L L
A. A.
1824 Statesville Avenue, Charlotte, NC, 28206 {t, fL
Pln k d Address City.and Zip 2t.It t
WATER SAMPLE W/SP-22 en C i' l
Mecklenburg t,rY
i.
(;enoh Parcel idesalfkation No.ON)
lab.l.,atitudc and Longitude in dcgrrea/minateslsmrols or decimal ddgrcer. 2L Ccrtil•rcation:
(lf sell fad,some 1100fis 1r xrdricieta)
W Bria.n- Ew_.,i ng, .. 10/13/2021
Sigruanee ofet;4cd Weil Conowtor Dak
6.is(are)the we11(9): JPermauent Or ZTemporary By signing Chit four,thereby cerfi6-that Me nr/lfs)+Fax(wire)twnrrracted in areordimrr
ndrh 1SA NCAC OX.0100 ar 1 SA NCAC,02C.0200 Well Consiruedm Steinddris mul that a
7.Is this a repair to as existing well: Oyes or ENo rape rrrrhk nvonf has'Nern proeldnd ro Ar nr1l awrrr.
If this it a rMdr.Jill revs kmmn writ.roemnA rim,hifruwwrimi am/replan the mmre of rhr
repait aradtr g21 mmarks.tewvian or an the bark o/this forth. 23.Site diagram or additional well details:
You nmay use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also aliach additional pages if necessary.
For nwh1fdo iR(teAM(W NtNi-sivrer UIW&wells ONLY sthh rho somt Mnsftwdon'yaw edn
sabmU one frmn. SUBMITTAL INSI TIONS
9.Total well depth below land surface:. 35 (g1•) 24a. For All Wells: Submit this form%(thin 30 days of completion of%tell
Form hlple wells list all deptkt constmction to the followinG:
10.Statie water Inel below top of easing: (gt,) Division of Water Resoureex,Information Processing Unit,
If wham let-el is.rbtiue waling,cyst,"+ 1617 Mail Scnvim Center,Raleigh.NC 2 7699-1 6 17
11.Borehole diameter z.25" (ia) 24b.Eor(p Won Wells ONLY: In addition to sending the form to tie address in
24a above also submit a cM'of this form within 30 days of completion of%tell
12.Well construction method: DPT construction to the following'.
(is.sager.tatar}.cable ditedpash cec.) Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center.Raleigh,NI C 27699-1636
13a.Yield(gpm) Method of test: 24e.for Water Sappy&inj xe'thm Wells:
Also submit one copy of this form;%ithin 30 days of completion of
13b.Dishrfection type. Amount: well construction to the cmmty beatth department of the counh•where
consmicled.
Form GA'-1 Montt Carolina Daparfmem of Em-iraimma aid Nanoal Resources-Di idoo of Nrater Re toutes Ro isedAi 2013