GW1-2021-08009_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Irrternal Use ONLY:
The form can bo awd Fr sirlgk of mullivk%ells
3.Well CDnmetbr Information:
14.WAl'M 7.ONE3
Brian Swing FROM TO DRSCRiP"O\
%Vcll Controam Kamm ft. fl.
4240 B
NC Well CorarctorCenifm ion Nusuber IS0UTF.RCASiNG Onraaihkawd weR4ORLIM it Ig AatbI
FROM TO MAMF.TER THRIO M MATERIAL,
SASDACCO Inc 0 ft. 20 4. 2.25" f It. NA STEEL
Can+pttn Naar T TNNH3tCASINCOR1f17fBfNG heflmt a
FROM TO DGMFTER T111CKNESS MATERIAL
2.Well C-onsaructtnn Permit 0, IL rt.
lia all wWiruble well pem its(Ix.Cwnir +.Srtrm.Varkme.lfjt*r idrt em) tt
3.Tell life(check well use): 11 SC
Water Suppl elh FROM TO cunuTBR. 4TS17r -rH1MXr95 I MATRRIar,
DAgticultuml OIYhlnicipall tbliC 20 ff. 24 ft, 1.25" la 004 NA STEEL
ClGwftn tal(Heatiilg/Cooling Supply) OResidetitial Water Supply(Single) ft. ft. 1a
Oindustrial/Cornme vial OResidential Water Supply(shirred) 1&L3R0UT
FROM TO MATiiRiAL I 11%ffq<CEMEXT!MrTrlOD&AMOUNT
Oirri tion (L n.
Non-Water Supply We":
ft. R.
MMonhori 0Rccovcjy
injection Well: R. R.
❑Aquifer Recharge OGroundtratcrRemcdiation t .SANDiGRl1VHS.p 0
4Aquifcr Storage and RccoNrly 13Salinity Barrier FROM TO T+tA slot.- RMPI A. tKVr�11 TF1 n
R. A.
❑Aqu ler Test DStommatcr Drainage
01EVcrimMal Technology l7SnbsiderreeControl [MIAM
NCSASG recMaddMlmro3ahcelatfrrccessa
❑Geothemml(Closed Loop) ❑Tracts TO IDWMtMOV esbr narde *Wrack dare ear s
oGeothennal(Heating Coolit Return) []Other( ain ultder 021 Retttarks) 10 (1. FILL SILT AND SAND
24 ft SILT WET PWR
4.Date Well(s)Compieted: 10-2-21 WellTDKGW-10 (L
Sa.Well Location: ft,
Former Charlotte Army Missile Plant R
Faeilil)lOanerName Faetlib-ID#(irappiieable) ft. IVQ�-�
202
1824 Statesville Avenue, Charlotte, NC, 28206 h.
Phiskal Addwss City,and Zip
Mecklenburg WATER SAMPLE W/SP-16 W
C'"My PAMO I truiricallonNO.(PIN)
:St►.Latitude.and Longitude in degrts/minutadseconds or decimal degrees: 22.Ccrtifleation:
(ifuetl Geld,met lablorg fs sidrtcient)
N W _ Br .a.n.Ewing. 10/13/2021, e�
Sigaalmre ofCtnilicd Well Connector DOC
6.Ix(are)the we11(s): OPermanent or oTemporary S1•,Ivdn#this fntm,i ANrbt•rertife these the xefl(s)rats ft rm)twatrueted in aecordance
wYtlt I SA NCAC A2C.n1(M►or l.S+t ArCAG R:C.1120(I R'ril Ctursrntcr(rul SrnuQnrds and+1utt a
7.iS this a repair to an existing*well: Mrs or MNn t is njtAir mrnrrf hqr 1mm pmritJtd to 1Mr Mrtl mtiur.
!f thlalt o reyerlr,�ll eK+tk»nnvr uvdl cnnsrtut ei�m Grfun+vrtlitur oral rr)+Jatn tlu<rwrrre�rltr
rrrytir rcndrr s21 nrnarla ze,etrarr nr cm the hat nj rAlz form. 23.Site diagram or additional well details:
You May use the back of this page'to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also ntlach additional pages if necessary
For ntulrlpP hPAv itul or ttru-w ner,wpply%•ells ONLY MA the mor ctrtrattrrrrtoar,ytw can
submit mse form. C IBA i FTA :INCT iCTIONC
9.Total well depth below land surface:--
24 (fi.) 24a. For All Welts: Subrudl this form within 30 days of completion of well
F'ormultipleWINS KJ700depthy(ldif(erent(ermmp(e-3@200'aAd2Q1iXT) construction to the folloning;
10.Static water tet•cl below top of easing 010 Division of Water Resonmes.inf walstipn Proeets.eft UnIL
1/ar+ter iekyl tr ahove(,same,am'y' 1617 Malt Service Center.Raleigh.INC 27649-3617
11.Borehole diameter:2.2-5^ ()n) 24b.Egr tDjectlo_n Wells ONLY: In audition to sending the form to the address in
24aabove. also submit a copy of.this form within 30 days of completion of well
IL Well consarpetlon method: DPT Construction toile following:
(i.e.Margo;ratary,cable.direct push ctc_)
Division of Water RcwOrecs.•Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636131n11 Service Center,Rateigh,NC 27699.1636
13a.Yield(gpm) (Method of test For Water$ai►p &tnJeection Wells:
Also submit one copy of this forin within 30 daysof completion of
13b.bisinfeWou type: Amount: well construction to the county health department of the counh•where
constructed.
Form Gott-i Noah Camtim D.-pmummof£m•imnniem and Nannal Resources-Dhisbnof Waict Reoutes Rcvi&cd Atgu9t 2013