GW1-2021-08011_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Imcrnal Use ONLY:
This form can be used for single or molt iple antis
1.Well Cantractor information: �
14,NVATER IONIZ,
Brian Ewing FROM TO OPS. IPTtox
Well Contra w Narm R. A. I
4240 B h ft.
NC well Cordswor Cenifawiion Number 5.OUTER CASING41ar Mktswd [1R_UNF2t It'
FROM TO DtAMETRR T"K%1 F.SS MATERIAL
SAEDACCO Inc 0 h. 20 h. 2.250 a. NA STEEL
t:aatpaun Nantt f IIVN@AC+1SfNGt1R 177BIKG lkottrmtl®seA i
FROM TO 1 DIAMETER I TtnCh.'�'ES3 I MATERIAL
2.Wctt CAnstruction Pemit#: h. h. to
Litt all upphnablr unell prnwiO(i e..County,Slatr,tpriamrr.I11'e^dca r1r.) fl.
3.Well Use(check well lase): 1
Water Supply'Wdl: FROM TO PlAMtSTP,N StJOT stzs Trr1(tciP s MATRRIAI,
DAgricultuml DMunicipal/Public 20 h. 24 h. 1.25° in 004 NA STEEL
Meothermal(Heating/Cooling Supply) DResidential Water Supply(singie) fL tt in
Clndustrial/Commerciai 011esidential water Supply(slated) I&GROtti
FROM I TO MATERiAL EMPIAfTMEST METnOD d AMOU.W
131niontion tr, h.
Nan-Water Supply W ell: h. fir
�Nfonitorin ❑Rccoti
Injection Weil: h• h•
❑Aquifer Recharge QGroundviverRcmediation It.S D/GRAVB3.PACK awkilbu)
❑Aquifer StomSc and Rcctnrty QSaliruty Barrier FROM A. MATFRrAi, M MrT11 n
❑Aquifer Test OStornmatcr Drainage
R. fG
❑Experimental Technotog ❑Subsidcnce Control ti.OG atrro
❑Geothenual(Closed Loop) ❑Tracer OM TO DESCRF TIOx❑Geothermal 4Heatit t Cooli Return) ❑Other( ain under#21 Renaud (L 10 fL FILL SILT AND SAND
h. 24 1L SILT WET PWR
4.Date Well(s)Completed: 10-2-21 Well ED#Gw-8 h. h.
So.Wto LAWathtn: (L (L
Former Charlotte Army Missile Plant tL It.
Facilty/OarrerName Facility 1DB(ifapplicable)
-
1824 Statesville Avenue, Charlotte, NC, 28206
Physical Address Cily.and Zip 21.KEM RIGS '
Mecklenburg WATER SAMPLE N/SP-16 �r.'A�RP„1 ✓� ilituli�(v
Loamy Paled IderaiftcadonNo,(PIN) UCNNNGUNII
Sh.l attitude and I:ongttade in degrres/minutetslseconds or decimal dtgrew. 22.Certification:
(it aCll 40d,mx 1*10 ih is srdfickidl,
N W _B ria.n.__EWing, _„ 10/13/2021
Sigrawre ofnifr Ceed wen Contactor Date
6.is(Frye)thewdl(s): OPerimment or ZTemporary By signing thit foam,I hereby trrly that tht urfl(S)east(Krrrj amtmrered in arvontwty
h;0 154 NCAC 02C.01OO or 15A NCAC OX A200 Well Constrrw non Sta+rhards w0 tlxtt o
7.Is this a repair to in e:e*npwell: ❑Yes or M emy of rhG reconi has bem prm-lded re,rhr well matter.
1lthtals arcprtlr,fill s+rrr Guanvr nwrllreMrrrucrtn+a 1>rftrmwrrltnratad rr(rl'arltr slM rtattrrc ref the
repair carder#21 remarks etv-flan a as the bark offlik force. 23.Site di*nm or additional well details:
You may use the ba of this page to pfmide additional will site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if tmcessary.
For awed 4e i+$ecth,rrax mrrr•umer A4er4y a ells©aY/,l'hSrh dw snore eonstraetiar,you MR
smbauitameform S,j,RAMTA .slim TIANc
9.Total wdI depth beta land surfaec 24 (>t•) 24a. For All Wells: Submit this farm uithin 30 days of completion of tall
For mplliple cells list all dep0s ffdiBeren;Oxamrpte.3@200'aAd 2 '-1O!T) constmcdon to the folMwiiW..
id.Static water te%*1 below top of easing (ill,) Dhision of Water Resimr our Information Processing Unit,
1/ttw 3rrlevel is obove enring,are"a" 1617 Mail Seniee tester,Raleigh,NC 27699-1617
tl.Borebc►k diametCr 2.25° (in) 24b.For in on Welk ONLY:: in addition to sending the form to the address in
24a above. also subunit a copy of;this form within V days of completion of%tell
12.Well consttintion method: DPT c nlstrucdon to the following.,
(i.e.akw.,cowry.cable,direct pWx etc.) Dh islon of Water Rexot mes Underground injection Control Progmat,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Service tenter.Raleigh.NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water Sugpls&in`ectio Wells-
Also submit one copy of this form within 30 days of completion of
13b.Disinfection t)Tc .� Amount: uctl construction to the count hcaith deparmurt of the co"M where
constructcd.
Form GR'•I Notth Camlina D.^ponsacm of Emiarmirm and Natural Resources-Dhis Ion of NVater Resotrees Rcviwd Atgkd 2011