GW1-2021-08013_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For rvenml Use ONLY:
This fonn con tx used far single or multiple wells
1.Well Contractor Infortuatlon:
Brian Ewing FROM 10 DESCRrr"Aw
yl'e11 Conhnctm Nan*
4240 B
NC Well Cafnfsctor Coniftcalion Number `1 .0131711 CASING after rnoKkated st OIt.T.UM if antaSCaA
FROM TO DIAMETER. THKK1FrS3 MATERIAL
SAEDACCO Inc 0 R, 21 (L 2.25" Is. NA STEEL
CoMiny Naar 16.INNER CASING OR TUBING eatltcrtl+attloraeda
FROM TO DIAMETER TIU N'ESS MAURIAi.
2.WellOmstructhln Permit k (L n. ht
List all applirah_!r u>ll perrWu(i e.Couwh&Sfwe,Variam e.11*do%rtr.1 R
3.Well Use(cheek well ae): 1718EEN
Water Suppl•Well: FROM TO DIAURTRR sr s1rE ntK"rM I MATRRiA1.
DAg ictllniral DMtinicipal/Ptdllic 21 R. 25 (L 1.25 a ilk .004 NA STEEL
OCleothemtal(HeatinglCooling StWly) DResidentiai Wtfter Suppt,(single) (L it, in
oln"strtal/Commercial ©Residential Water Sttpph•(shared) I&GROtiT
FROM I TO MATERUL I LMtPtACVKM Mr M0D A AMOUNT
Dlni on R. (L
Non-Water Supply Well: R. (L
MMonitoripg DRccoirly
Inject on Well: tf f4
DAquiferliccharge DCrroundafitcrReutediation 19.SAt!tD PAt:IF 1' k0ble
i7Aquifer Stolmgcand Recomiy ❑Salinity Harrier FR HfATF,kIAt. 1!MPt AST1tRVT MiTNOn
R. R.
13Aquifer Test 0549mm-atcr Drainage
ft. ft.
❑lExperimcntal Tahnolog► ❑Subsidemc Control
20.DRILi.1N'G flttaCtt !l/Lit1�11S11 tMt>1b ttACaRFfI
❑Geothermal(Closed Loop) ❑Tracer FROM TO Dr;5CRrMoN eaht:hardneev N.Wrrltk t*j
DGeothermal(Heatif li Return) 00ttw(vtplam under#21 Remarks) 0 ft. 10 iL FILL SILT AND SAND
10 R. 25 (L SILT WET PWR
4.Date Wetl(s)Completed: 9-26-21 Well M#GW-6
IL n.
5a.Well Location: ft. h.
Former Charlotte Army Missile Plant 77
—
Facil"rlylowrrf Nanic FaeuitytDN(ifappiimble) T
R. n.
1824 Statesville Avenue, Charlotte, NC, 28206 fL R,
Pbysicui Address City.and Zip 21 86 M
Mecklenburg WATER SAMPLE W/SP-16 [rr E,zi U1I0N;
1, -r1f3°at
Gduitq PamelldentinCalionNo.(PN) " I V ! 7
5h,t,atitudc and LonRimde in degreeblminutc0monds or decimal degrees 2L Certification:
Of hell fiittd.Pre I:rb'lar c fir srdticknf)
W Brian-.-Ew1n 10/18/2021
SignaMmofCertifledWcllContmernr -� Dmc Y
6.Is(are)the well(Q: OPermanent or zTemporary
N}•signing this farm,l hraeiry eerrifv rhrar rhr arll{s/ribs(airrrn)ianrrrurred is arcvoada+ur
with 15A A'CAC OX.01 M or 154 XCAC QC.020 WrU ConornrW(w Smadar4b and duel a
7.Is this a repair to an existing well: oyes or MNo ropy of thin word hasireen prorldrd to the aril ouner.
tf Phis Ir a rexxdr,fill owr h %w will rorurmviaa in/ormo"r and explain the riarare r>f rhr
repair underrf2l remarks seruan ar on the Dark of rhis)brac 23.Site diagram or additional well details:
You may use the track of this page to provide additional tteil site details at well
$.number of wells constructed: 1 construction details. You am also attach additional pages if necessary.
For Awhi ale irtf rc1kVj a am-»orer,rrtppls walls ONLY srde mme conarrartlmq yov twn
.sabarir oar four,. rh th SUFIQ111TAL INSTtlf'1 ONS
9.Total well depth bekm land surfam 25 (II.) 24a. For Ari WOW: Submit this fonn uitbin 30 days of completion of%til
for mAiMple urKr lia all ritlul+t if Qlllrrrnr lcaaraptr-J�2tK>'Parr 2 lfkl i construction to the follotsin
10.Static water level below top of Casing: (pl,) Division of Water Resources,Information Processing Unit,
If iw. er level&dtio a raslag,use^+" 1617 Mail Service Center,Ralcildt,NC 276994619
11.t3iarcllnlc diameter2.25" (;n) 24b.For into IM Wells ONLY: In addition to sending the form to the address in
23aabove also subtuit a copy of;this form within 30 days of completion of utit
12,Well construction method: DPT construction to the following:
fix.roger•,rowry,cable,dired,pusk etc.►
Division of Water Resources,'Underground ilnjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleiib,NC 27699.1636
13a.Yield 24c.For Water Sunpil dlc InJocthrh Wells:
(Rpm) Method of test Also Submit one copy of this form within 30 does of completion of
lab.Disinfection hire: Amouat tiveil construction to the eofmty d'rya,lth department of the coamro inhere
constructed.
Fenn Gttr-1 Noftb Carolina i7qnrinrena of Envimimm aid Nannal Resoumes-Division of R'alet ReSbtreG Revised AWRA 2013