GW1-2021-07993_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For imermlUwONLY:
'nis-rormcan W itscd ror.sin&or multiple sills
1.Wdi Contractor information:
ti,3R'Ahf3lt ZONI
Brian Ewing FROM TO DRSt•'RW"ON
U101 Coatraaao.Harm
4240 B R
NC Weil Contractor Ceniriention Number 13 Ol1TRR CAS1NCa or rmnttl i6rfls OR:1 1!r0t R a Narb
FROM TO DIAMVVER T"j1x1WM MATERIAL
SAEDACCO Inc 0 h. 20 rL 2.25" . is. NA STEEL
Cot vaq Kam 16.INNER. CASING OR IVRING, tlkvraid —490)
FROM To DIAM il'iit Tfti ASS MATERIAL
2.Well Consit•nctlon Permit#: rL ft. i9+
list all aWi(YAbir mdl primUs fir.:County,Stpar,I ariaa[e.1tWto rlt.i
3.Well Use(cinch:well use): 1T
Water SupplyWdl: FROM TO p1AAtRM SIOTS17T. T111CVCNM I MATERIAL
OAgrk-ulttllal ClMunicipaumlir 20 R. 24 (t 1.25" is 004 NA STEEL
Mothennal(IiearingCooling Supply') DResidential Water Suppb)'(single)
DindustriaUContnxtciat G1Residential Water Silpph(stated) 10.GmOT
FROM I TO MATERIAL HMPLtCEMI`�t�T METHOD&AMOUNT
Otnn lion. he h.
Non-Water Supply Well:
R. IL
Glvlonhori!>R ORaoLc '
injection Well: R. (L
OAgniferltceharge QGroundmaterRctticdintion SANDMIUVEUVACWdJ }cable
QAquifcr Storage and Recovety OSalinity.Barrier FROM R. TO h. MATrRIAI. FMat r• tr.�t:H1 TnOn
❑Aquifer Test OStor matcrDminagc
E]Expctimcntal Technology ❑subsidcncc Control
20.DRlh,t3NG I012 tsttrcb addilinm►t:t>tnnisif,ncc
OGeothemtol(Closed Loop) oTtaccr FROM TO or-%RtMOV c6bt'blirana WWn*k tjoe,own*v etr.►
oGeotbennal(HeatingCooflnge Return) 00ther(exVlainudder#21Remade) 1 0 fL 10 (L FILL SILT AND SAND
10 h, 24 (t. SILT WET PIER
4.Date Well(s)Completed: 10-4-21 Well ID#GW-15 R. fL
Sa.Well tAlcatiiln: (L (L
Former Charlotte Army Missile Plant fL (L
Facility/Owmr No= Facility iDk(if applimble)
R, ft.
1824 Statesville Avenue, Charlotte, NC, 28206 R. IL
P)nskal Addmss.City.and Zip 2!.VILMARMS
Mecklenburg WATER SAMPLE Ai/SP-16
CMMY Pamd ldeteiffeation No.(PiN) L)f;A;l 'iCIIOh
Sh.lAtitade and Longitude in degrw4minutes/mctinds,or decimal degrees: 22.Certifacation: r :�cCl�'Ir(J•ji
(itxcll field,w t lanaau is ttdfieleal)
N W Brian .Ewing. , 10/13/2021
Sipmyr orcenified well Coutmetar Die
6.Is(are)The.well(s): r3Permanent or -MTcmporary
05,signink this form.1 Aerrin•ttirtifi•that the xrlllxj Karr(r+r>p)cricrrnnTed Graragrdant+r
with 15A NCAC-MAIN)ar f.Li NCAC 02C.0100 n1ell Construr.d ut Stawfards oral spat a
7.Is this a repair to an existing well: Oyes or VNn rmpr oJthir►trnrd hoe hrrn prm•ir&vl im alrr'ttrll mw,trr.
iJrhta we n rrpprlr,fj11 t+at knnata xe1!raostturtf+nu fmfurmmtinn mad rxyfair tAr turrpre mf rhr
repair ander s21 rcmanlr.ra:taaa or art the hack of rAis form. 23.Site diagram or additional well death,
You ntag use the back of this page to pto%ide additionat%mil site details or well
S.Number of wells constructed: 1 ccrostmction details. You may also attbch additional pages if necessary.
Fro nt"hiple 1trJec"1 M twi-HYirer suprJy uyffs ONLY nirA.thP merle conaravretim,jWM two
xUbmir me form. SURNICUAL INSTUMONS
9.Total well depth below-land surfs= 24 (ft.) 24a, Par All Wells: Submit this fame within 30 days of completion of nvli
For maktole writs fisreftdrpthtffd*rrnr[cxmnpP,-MW'mud2@1ATj constmciionto the foilcming:
10.Static water level below top of easing: (D,) Division of Water Resaur+ts.information Prvicesdn*Unit,
lfwnser kvrl isahove rdainR,air•'+" 1617 Merl Senice Center,Raleigh,NC 27694-1617
11.Borehole diameter 2.2 5 24b.ulna Wejb ONLY. to addition to sending the fomi to the address in
24a abm•e, also submit a copy of this form within 30 days of completion of-.veil
IL Well constMetion method: DPT construction to the following:
Ue,anger.rotary.cable.direct posh etc.)
Dhision of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLYAVELL4 ONLY: 1636 Mall Service Center,Rateigit,NC 27699-1636
24c.For Water 5uppil&tndoclton Wells:
t3a ti laid tgpm) Method of test Also submit one copy of this form qVitbin 30 daysof completion of
13b.Disinfection trpr; Amount: well construction to the county health dc;mm cut of the connh•where
constructed.
Form GW-1 Nonh Carolina Depmttmu of Etn•imitmew wd Natural Rcsoumcs-Disisian of Ulticr'Remutes Rc,'ised Artg O 201.1