GW1-2021-07994_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Imernni use ONLY:
Wis krnntan be awd for single or mulliple suds
1.Well Contractor Information*
Brian Ewing FROM tO NSCROW"OY
Uetl Contiac(n warm
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4240 B
NC Wei)CoraractorCertifstationlitu*tr 13,Otffl<R tl<iCl renrd iseil t)RLIT t ifi tieabk
FROM To mmWITER TtiiCrt,NM MATERIAL
SAEDACCO Inc 0 fL 20 rL 2.25" in. NA STEEL
C"q mkNsrna 1 11zicEER G-ORT(1$tKG' tletntfl a
FROM I To I D101E.TM I TtnC6ME.SS I MAWPJAL
Z.Well Connruction Permit'#: ft I N.
ljo-01l4marable wetf permits fine-County,Starr.Varia"re.'*rVert rn ) A. iL
3.Well Use(check well nee): 2.:Si itEEN ,
Water Supply Well.. FROM tO nrAmrmR '51 iorstrr I 'MlmNffl I NArr.Rrn1,
20 ft. 24 n. 1.25° in. .004 NA STEEL
t�Agtictitttltvl ClMilnlCipr�VFubilC
aGeofhermal(HeitingCooling Supply`) oResidetitial Water Supply(Slagle) ft. tL IM
OladostrialtCommencial OResidcrtnai Water Stupid,(shared) '3.R,4MR0L1T
FROM TO ?"TENAL I E M7'tflQn fi AAT IitY:i
01nigation
Non-Water Supply Well: rt. it.
mmonitonn Oltccotivfy
Injection ell: (L
DAquifcritcch.•urgc 00routidvmterRcmcdivOonO.SAXBit; LI'At i'
Fa M TO MA arAL RMP1 A.MAT Affa n
DAquifcrStorage and Recovery QSalinityBamer ft. ft,
0Aquifer Test 0Stommatcr thttinsgc
ft. ft.
0Eagxrimctitat Tcctmotos y oSubsidemc Control
i'R0.1lRtI. {itA(k attrdlladd3AoasllstKeislf:
oGeothemwl(Closed Loop) 13Tracer FROM TO onscitwin srtse.acsranc nr+,ca Curl,
oGeothetmal(HeatiMICooliage Return) 00ther i sin uttder 2.1 Renlail;s) 0 fL 10 (L FILL SILT AND SAND
10 ft, 24 fL SILT WET PWR
4.Date Wetl(s)Completed: 10-4-21 WMl SGW-14
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SM.Well Locartinn: h. it.
Former Charlotte Army Missile Plant tt. (L
Faci1kXhvoctName Facility tDti(ifapplicabte)
tL ft. U A .�
1824 Statesville Avenue, Charlotte, NC, 28206 R NOV A 2
Plgsiaai Aomss.City.ard,Zip 2t R' ARt{S' �V V 6r
Mecklenburg WATER SAMPLE W/SP-16
Conag PuaseltdeidAwtionNo,(PIN) ( 'FORIVATinm pc�rrn;43:i 1i i
Sh.I atimde and Longitude in degrecs/mlrlutes/scconds or decimal degmm 22.Certification:
(Itwefl Actd,one Wona it tufile t9)
W Brian -Ewin 10/13/2021
Sim of C<rtrtied WWI conitactor Date
6.Is(am)tale-ttittt(W. 0Permanent or $iTernporary 8),Filming rhu o+m.1 hercbr efffi .that the I rws)was f ie)tw1w)"rctrd In awordmer
with 15A NCAC OX.01M or 1SA NCAC:a.1C.0200 OYU Constme near Standards andthar a
7.Is this a repair to an tsisti"well OVex or WNo mpy of dur nvonf has torn farm44M to Aw Furl!tm rr.
rf rhis Is a rgWr.fjk cat Awnita aril em ma a(M l ormrataJon and exprnin the nartare of the
repair antler E21 rrnwrkY xr flox or rm thr sat:afthis form. 23.Site diagram or additional well'detalW
You may use ft back of this page to ptnt7d additional ivel)site details of welt
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For ntufrrr4e ft*ak it*ata mower.tayph wrfit©d'f;?`wit/r clue reranr enrrstnutdan,you smo
xaabm re+aae farm. SUBMITTAL 111tU[)G`TiUS
9.Total well depth below land surface: 24 (R.) 24a. Far Atl Wells: Submit it"faro! within 30 days of completion of well
For m1rWo,x-rfh list oft depihs if tfi ftrrru(exaMp r-3@ 00'and 2kb1(#T) construction to the•foltoning:
10.Static eater ie►•M belovr top of casing: (ft.) Dh•ision of Water Resources.information Processing Unit,
lfxnttr hVel ixtttroet.�rsfo,?,rust"+" 1617 MA I Service Center,hale gk NC 27699-1617
11,Ilorchnle diameter 2.25° (in) 24h.E LIglkoggL'S!'S »ONLY, in addition to sanding the form to the address in
24aabove. also submit a copy of this form Lwitbin 30 days of completion of%sell
12.Weil aatrsh ellov method. DPT Construction to the following:
fie.garStr-ratan•,cable,diteca past ctc:)
Dh islon of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY- 1636 NO Service Cebter,Rai ft.WC 27699-1636
13a,veld(item) Method of tew 24c.For Water Supply&Inicction iWeW
Also submit one copy of this form:rt•ithin 14 days ofoompletionof
13b.Dixinfmttnn h'pe. Amount: well Construction to the county health depasttuxrlt of the county where
constructed,
Form Ml-t North Combos DgxWnwm of Emit a m m wW Nanvat Resormacs-1Di%*ion of Staater Re ottras Rcvlscd Atdust'!013