GW1-2021-08015_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used forsingle or ttudlipk wells
1.Wdl Contractor tntornlatlon: E
14.WAII ZON
Brian Swing FROM TO I DTSCRIP11Oe
%N°eDl Contridm Name R. R.
n. n,
4240 B
NC Well CatllntctorCertilimlionNunbcr 2 t)tliF.ltCASfNCr ortrtathlatSedN OR g "lkab
FROM TO DIAMETER THICKNESS MATERIAL
SASDACCO Inc 0 R. 21 ft. 2.25• In. NA STEEL
Coa vmry Namc 116,114M CASING0R 77}1tIING hertm f cloced t }
FROM I TO :DIAMETER THICKNESS MATERIAL,
2.Wdt Constructinn Permit# R rL In,
Lin all awUrabIr urll permles(i.r.Caunh•.Starr.Varianrr-Iftereal rt(,.)
3.Well Use(check well use): 21.5
'Water Supply Well: FROM TO 1 DiAM►Tillt;I Si Says: I THICU W I MATP.RTAI.
❑Agricul'Mral Dmunicip©UPrlblic 21 R. 25 ft. 1.25- IR6 .004 NA STEEL
®Geothermal(HeatingC:ooling Supply) OResidentiat Water Supply(single) ft ft. la
Cibndustrial/Commercial ❑Residential Water Supply(shaved) B CROur
FROM 170 MATERUL 0ff`1 ACVMLNT MMOD&AMOLWT
011ni tion R. ft.
Non--Water Suppty Well:
mmonitoda Mccovvy
Injection well: R R
LlAquificrRcchargc ❑GroundwaterRcnlcdiation 10..Ss"0pGttAVELPA ilr dkiblt
❑Aquifer Storage and Rccorcq OSalintry Sar R.
icr a0>ro TO a►laT;RrAr. FMr1 A�F�irYTMITNon
rI.
❑Aquifer Tcst ❑Stonir ater Dminap R. ft.
OExperimcatal Technology OStdi Bence Control
110. RHAJNGLOG tdtac6Addl le1witheets Ifeectmni
❑Geothermal(ClnsedLoop) ❑Tracer FROM I To OFSCRnFrro\it»br.t+udneel xi�IVCk n eta.
❑Geothermal(Reath li Return) ❑Oti>er(Ocpbin under 021 Remalits) o R, 10 ft. FILL SILT AND SAND
10 rL 25 (L SILT WET PWR
4.Date Well(s)Completed: 9-26-21 WdIIDAGW-4 (L It.
5a,Well Location: h (L
Former Charlotte Army Missile Plant R. (L
FacilitpOwncr Name F3014 1Dll(ifapilicabie)
R. f1.
1824 Statesville Avenue, Charlotte, NC, 28206 R. f4
Physical Address.City.and Zip It RSM
Mecklenburg WATER SAMPLE 9r/SP-16 Iyuy
Contuv ParcelIdet N-itlon No,(PIN) SECd"
5h.Latitude and Longltade in degrsWmimiteslsceondsor decimal drgrem. 22.Ccrtification:
(itutiltli W one Wong is W116 no
N w Bria.n_.:Ewirr 10/13/2021
signmir of Ccnifiad Well ContraetoT �-�� Date -g
6.is(arc)tits wdl(s): ❑Permanent Or zTemporary Br signing the fame.I hereby,rrrdA-three the iwfNsi sma{ywre)vowrmereed in acrotdMee
W0 15A A'CAC 02C,01W or L fA A'CAG 02C.0.100 Wet)Comintctfon SmMaods and rant a
7.Is this a repair to an existing Nell: Mes or W Nn ropraf thi>rerord ho.bem pmi-hkd to she aril mteter.
If ih(s:it a repair,fill out 4noKet uYll consrnh7tan Inform*wt and r.%*ia for)u7rare of thr
reliuir urglrrb2l rrmarkx xrrtr'an ar art tar bar&etthis farm: 23.Site dlagtam or:additional well details:
You may use rile lead;of this paige to proide additional well site details or well
8.Number of weds constructed: 1 constriction details. You inky also attach additional pages if necessary
For nwlilple in/mrhur#v nm-vtwr,rV#,v u-rth ONLY ul(h dw ranee r n—SI tallm,you can
aubmiraar fnnn. SUBMLTTAL INSTIIOMS
9.Total well depth below land surface: 25 (n,) 24a. For Ail Wells: Subunit this form within 30 days of completion of well
For maMple wrlls 1ix1of1 dq A1Ifd*nrn)lrrmApte-3@'2M*and 7@e i(ili'1 construction to the twloning;
10.Static water letel below tap of casing: (1t.) LHvislon of Water Reti(wrctes,Information Processing Qni4
lfwaree level it alwwe twsing.&w^+" 1617 t tit Seniee tether,Raldgh.34C 276999-1617
11.Borehole diameter.2.25" (in.) 24b.Far Inhrdon&dLa ONLY: In addition to sending the form to live address in
24a above. also submit a copy of.this form within 30 days of completion of well
12.Well construction method: DPT construction t0 the fb110,,oing:
(i.e.altgu,taraq.cable dirrxi pack t tc_) Dhislon of Water Resourees Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Malt Senice Center.Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test; tic.For Water Sap&&injection Wells:
Also submit one copy of this Porn'within 30 da)-sofcoinpletionof
13b.Disinfection"v 4m Amount: w•eil constniction to the county 4ahh depaninen of the county where
congmctcd_
Form GW-I Nomb Carolina Gcpdnsyn of Emirotintem and Nnninil Resources-Divslon of Water Resotron Revised At4+,uett 2013