GW1-2021-08008_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For frknW Use ONLY:
Ttis forntcan be asod-far single or nniltift welis
1.Welt Contractor Information:
a.:WATERZONES
Brian hating FROM TO ORSCRIP11A.
N"ellContratiorNam
Q. R.
4240 13
NC%4cIlCordwor Crrti6cntton Number 11l.OUTER CASING ar tturliki ned vGeR bR.MMO(avilb
FROM TO DIAMP,TER TfliCKNESS MATERIAL.
SAEDACCO Inc 0 R 20 fl. 2.25° NA STEEL
Comp aiy Name 1 lPl1Q1@It 1NG aR TUBING rotIteeLed sieseA
FROM TO AlL DlI!TEH III TCKIlES3 MATEAIAI
on
2.Well Constructhln Permit*6
list all amucnblr roil pennitn(i.e..County.$iarr,t+ariarce,l/je:ut n err.) R. tt. ttt
3.Well Use(choek well use): �7.S
Water$uppl Well: FROM M DIARTER 5t M 11UMNiiS MATit 41
OAgikutntlal OMunicipKlt?Alic 20 ft. 24 ft. 1.25° Ie. .004 NA STEEL
Meothctmal(HeatingJCoohag Stt)tply) OResidential Water Supply(single) ft. ft. in
Clindustrial/Commercial OResidential Water Suppb,(shared) FROM
sROM I To ttlA'i'f?itiAil. ESiPCA+t>:sLI�T•MF.TIIon d AhtOtlNr
DIrrt tion n. rL
Hon:water supply Well: fl. 0.
MMonitorin Olttxor '
Injection Welk n D'
OAguifer Recharge OGrotindvmtcr Remediaaion 19.SANDIGIIAVEL PA to
OAguifcr Storage and Rcco,,"- OSalinity 13arricr FROM R. TO ft. staTfiR/At, ttMVL a. IF.CT MIT n
❑Aquifer Test OStommatcr Dminagc
R. ft:
OEatlactimental Ticchnotogy OSubsidcwc Control
20.DRU.CillG1AG -adtifflumilsbewiffteeggrrsl
OGeothennal(Closed Loop) OTtracer FROM TO DtrseR-tPrrr#x atar.�s�ra alomcx rlc
OGeothermal(Heatin lCooli Return) O0thef(ex0ain under i121 Remadm) 0 h. 10 IL FILL SILT AND SAND
10 f6 24 ft. SILT WET PWR
a.Date weI14)Completed: 10-2-21 Wef1ID#G W-11
a (l,
So.Well Incathtn:
Former Charlotte Army Missile Plant A. It. �j ,
Factflii)? ner Name Fwility i N(irapplicable) ft. It.
1824 Statesville Avenue, Charlotte, NC, 28206 O p, V
22
PM°sled Addtrss•Cih nMZip
Mecklenburg
WATER SAMPLE rP/SP-16 t;t}
0t/r
Caatny Parrot ldetnificaiion No:(Pi14)
Sh.IA#todc And LongitLtde In dcgrees/mimltcstseconds or decimal degrees: 22.Cerdtrcation:
(ifuetlllcld,one iatfttt Is strfikkrd)
W Br_. an . i�nrng_: .. 10/13/2021
Sigartm ofCertifxA Well Contractor Vale
6.is(are)the well(sr t7Permanent or ETemporary
By signing thin form,?hrrrhr aert/Jp chat the wriNs,w7rx(err')civarrrurred in arcandiatne
with 154 NCAC 02C,0100 or 1 sA NCAC.'AX.02(k)tt ell ConsIrwrtitul SM&IM is and Haar a
7.Lr this a repair to an ousting well: inks or MsNo ropy oftlik reread ism hem pmrirkwi to dw uril owner.
if this!%a repalr,fill ont taowvr well cnrurrtnvaon ittformikvrn mad explain Me ttarare of rite
rtpnirarnirr8?1 rcrtar&r vextriry or rxt the tkri nfdttx ,rm. 23.Site diagram or additional well details:
You may use rite back of this page to pmAide additional well site details or well
8.Number of Fells constructed: 1 construction detaft, You may al:ao attach additional pagm if necemn
For MAddrie rr{ltrtbrlor nrtrwvaer"10,wear ONLY With the Went constrtretiat,W*can C1BhiITTl:A ttVSTCICTION$
suMnironeform. C L -
4.Total well depth below land surface: 24 (R.) 24s. For All Well o Submit this form wilhin 30 days of completion of well
For amol8p4e wells lisr all dieluhr ifd*rent ?F lVor) constmction to the following:
10.Static water iet'el below top of cashtz (D.) Dh•ision of Water Resources,Information Processing Unit,
1/water level Is a6rme vasing,arse"+" 1617 Mari Scmice Center.Raleigh,NC 276094617
11.gorcholc diameter.2.25° (ia) 24b.For InkWgn We11c OM Y:'. in addition to sending the font to the address in
249above. also submit a copy of this form within 30 days of completion of tv,ell
12.Well Cttrlst UCtion method: DPT construction to the following:
(Le.anger.missy,cable,direct push ex.) DKIslon of Water Resources Underground Injection Control Program,
FOR WATER SLPPLY WELLS ONLY: 1636 Mall Service Center.Ralft.NC 276"-1636
13a.Yield(Rpm) Method of test 2.4c.For Water.Sapplr&Injection Wells:
Also submit one copy of this form Othin 10 days of completion of
13b.DislnfoLlion type.. Amount, well construction to the cot", heahh depsaman of the couray where
constructed. j
Fonn G1',r-I Nonb Carotirta.Department of Em imi ntt:ty and Nattua]Resomxs-Division of 1Yate►Resotrces Rcviscd ALV A 2013