GW1-2021-08019_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For internal Usc ONLY:
This forn can be used for sink or multiple rtidis
1.Wett Contracmr Information:
14.WAUR ZONtS
Brian Ewing FROM TO DrSCRir"ON
%Hell Cotormw Name ft ft• I
4240 B n. fL
NC Well ComsmatCertificat ion Nmnbm I&OUr9R CASINGffor iRlbca 141e ORUNER tf tkahte
FROM TO DiA.VrrER THKWNESS MATERIAL
SAEDACCO Inc 0 fL 26 (L 2.25" 1 it. NA STEEL
Canrptan,Nam 16.INM CABIN Q OR TUBING k-rtaai tlewddoo
FROM 1 TO MF.DiATE TMCKKESS I :MATERIAL
JAL
Well Con.struction Permit#: R. n..
tsu all app(irrdxir.+crf!pemrirs fi_e.Coump,Sfer,Variatre.110f an err.)
3.Well Use(check well use): 1 i.SCitCLN
Water Supn4.Well: rROM 'to DIAMETER St Sirs; '"11CU M MATRRinI,
OAgricultutal I:1Municipal/MliC 26 R. 30 ft. 1.25° is 004 NA STEEL
OGeothermat(HeatingtCooling Supply) OResidential Water Supply(singlo) fL tL to
i industrial!Gomnicrcial ORcsidential Water Suppy(slated) 8,ZiR u
FROM TO MATFML E1IPLACEMENT'MrMOD&AMOUNT
Dirrf Lion fL fL
Non-Water Supply Well: rL
i monitorin ORcm
in ct on Well: n-
OAguifcr Recharge OGeoundwatcr,Rcmediation I 5AN1) :P +f ktietl6c
OAquifer Storage and R=orvq ❑Salinity Harrier FR M TO MA RIAi. RMar a ,tr. r Mt Tn n
n. n.
0 kiuifcr Test 13Stommatcr DMinagC
n. n.
❑Expclimcnial Tachnologc 0subsidcricc Control
2tl.DRIM�l O WG.arlirelt ittdl airiil:ahects if t n
OGeodicrm►I(Closed Loop) OTracer FROM TO DIS5MF Q*- tstsr,6ora 6D01 k n lire!M¢.1
tem DGeotlml(Heatit ooli Return) OOdter(explain under#2 t Retuarit) 0 It. 25 ft. FILL SILT AND SAND
25 IL 30 ft. SILT tWET PPiR
4.Date well(9)Completed: 9-25-21 WellID#(;W-1 IL
Sa.Well Loc atioD: n to
Former Charlotte Army Missile Plant n (L
F•acilit)fOwnerNatnc Facllfty1D#(if epplicabte) n ft
1824 Statesville Avenue, Charlotte, NC, 28206 ft. n. F -
Pln-sicd Addles&C41y'and Zip 11.REMARKS
Mecklenburg WATER SAMPLE N/SP-16
Cormty PAMdIdeuulicvlionNo.(PIN) r,e vrtiSECI ION
5b.Latitude and JAngitude in,r....,nw fmimtic0seainds or decimal ftreer. 1NG i"I.
6tnrll Wd,+tits lar4ona itsulPickta) 2L Certification:
>, w Brian„fwl.na 10/13/2021
SiestmM of ccni0cd Weli cannactor Dyne
6.1s(are)the wdll(s) 13Permanent or ZTemporary Hy* kg ahir fumy,I hrrieln,rertoe that 10u wrlt(i)was(ntrr)rrmrnmrred lit nkvordamre
nirh 1 Fq NGAC 02C,Olp'1 or lSa NCAC n2C.02fdtllYr)I Cortstr+criasr Srnrulwifsentd,dxrr o
7.Is this a repair to an orisft well: Mem or ENo roprof rhiv arorihachrm pan-Ir rd m she ttr-11 swam.
rfthif h a repair,fill rm?t Roavi uV11 rrusrnrtd0"htf0MVrhM 4W r tlrla)n rite+u-Irmfe of fir
repair anderd21 rrwwrkv srrsian ar on the bark of this form 23.Site diagraot or additional well deMi►s:
You may use the back of this page to provide additional+cell site details or well
8.Number of wells comtrut:ted: 1 cotlsituction details, You may also attach additional pages if necessary
For nwhirde.i/t/res)rni oe omi."vrrrr xtq#y with ONLY u irh rhr some cotrsmsesims.yort rmv
submit ow form. SUBN MAL iNSj'UCTIONS
B.Total well depth below land surfaces 30 ((i(,) 24a. For Ali Wells: Submit this fort within 30 days of completion of well
For multiple wr)fs list tall drtubt lfdif arms(evrnpie-;tr 200'mx1201mr) construction to the following:
10.Static water Intl below top of casing: (D-) Dlvklon of Water Resources.Information Promaing Unit.
if urtrer kvrl is abtn-r cvalmg.use.^." 1617 Mail Sm ice Center,Raiclo,NC 27699-1617
11.Borehole diameter:2.25" (in,) tab.For iniMlinti Wgilc ONLY: 4n addition to sending the form to the address in
24a above. also submit a copy of ibis farm widtin 10 days of conipietion of well
t2 '%,ell cot?5"Wion method: DPT construction to the follouing:
(i.e.auger.relnr}•,cubic,dirt push etc.)
Dh'L41on of Water Resourccs.fUndergr'ound Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sereice Center.Ralelglt.NC 27649-1636
13a.Yidd(gpm) Method Of tea. 24c.For Water Sueghl &Injcctloti Netts:
Also submit one eoln' of this forth within 30 days of completion of
13l►.Disinfection tvpc:, _ _ Y Amount well consmiction to the county health department of the county where
constructcd. f
Fatm GA14 Noah Carl m Dq muwm of Em itomnod and Nanual Resourocs-!**Ion of Walcr tkemutfs Rcr,ised Augiuit 2013