GW1-2021-08021_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For imcmnl Use ONLY:
This fonn can be usod for single at mull ipk wads
1.Well Contritctor informatlon:
14.UTA7RR ZONil".S
Brian Ewing PRpM nPstRTnyn�
♦tletlCoatmowNdme f!. ft. f
4240 B R. n.
NCWcllCotdtscaorCenifxxtionNumber I&OU11P,RCASING raarlltarpedhell Q1t:LM if` Scab
PROM TO NAMITER T"TCKNFM MATERIAL
SAEDACCO Inc 0 fa, 21 fL 2.25 a 1 in, NA STEEL
Gornpran,Name J6.ILOM CASING Off MBING 4ze6tkqajd timed400
PROM f�jD[A.htETER T[tICKl�'ESS MATERIAL
2.Well CAnstrnctfon Pertrrit R+ R. h►.Lisa all applirabte weltperrefrs(ir.Coanh,$me vlaria"re.liftr en err) is
3.Well Use(check well use): t s
Water Supply Well: FROM To DIAnr►.Tr R VAOTS17Y, ticKrvRSS MATFRIA1.
OAgriculnrral DMunicipal/Pltblic 21 it. 25 fa. 1.25o'Ia .004 NA STEEL
OGeothemual fHeatingCooling Supply) DResidential Water Supply(single) ft. n, is
OlndustriallCommcrcial DResidental Water Supply(slxued) 'ILGROVI
FROM TO MATERtAL ERNACT RRY MMOD&AMOUAT
01irrigation fl. R,
Non-Water Supply Welk
ft. R.
@Monitori ORecgve •
Injection Weil: R• t4
DAquifcrRccharge OGroundwatcrItcmediation 19.'6ANII YRI.PAIK11r
FROM TO MATPRtAl. P.MP1A.71tEVTM. n
i7Agaifct Storage endRecovery OSaiinih°E3arrict
OAgtriferTea ❑StommaterDrainige
❑1=xperimental Tahnola Q5ttb dcncc Cattrvl 30.DRUAJNG tAc alf clt:addidedid Abeill tra a '
OGeothtmml(Closed Loop) OTracer FROM TD DiL"WTMN asbr.hardnen wWtwkf3pt,000 etei
Ot,rothetmal(HeatingCoolily Return) 00ther(explain under#21 Re ggdts) 0 ft. 10 n, FILL SILT SAND
10 ft. 15 ft, SILTY SAND
4.Date Wet1(s)Completed: 10-29-21 peel)M#SSW-Gtf-12 15 R, 25 ft. MOIST TO WET SILTY SAND
Sa.Well Location:
Former Charlotte Army Missile Plant R. rL
Facili y/ttwncr Nanrc Faciliw 1Dk(if applicable) R. n. g
1824 Statesville Avenue, Charlotte, NC, 28206 R. (L C
Plpskd Address City.and Zip 21:Rlr MARKS.
Mecklenburg SP-22 PLATER SAMPLE.
CAeuty Pared tdCniification No,(PIN) (par gs �:i•oal,Ilj-Y
Sit.Latitude and Longitude in iTnrtcasJscainds or decimal d
fitmetl field,one WotV is sidticieta) 22.Certification:
N W Bri;a,n_,.E�Y�ng,. -,� m, 11/2/2021 m�
si�tnre orcmifitd wen Contactor :Lae
6.[s(mv)the weli(s): OPermanent or zTemporary IN,sigafng ihit farm;l hereby eerrib,that+ihr mrd{.sti wary f"rarl tvnutmeted to artvAir re
rrlth 15A aVCAC 02C.01M or 15A NCAC MIC,0200 Well Coxsrnasitur Srawfnrds curt Mar a
7.Is this a repair to an existing well: OYac or MNo rape of rhir arrowd hashers pmrl"to ArI mrli ownrr,
tl this it a repair,fill.xuIntmw wed cortrmn3loo luformarkwr and curtain thr norare of rite
repair wider ni remada et+_tioer or cm the hart of rhir form. 23.SIlse diagram or additional well details:
You may use the back of this page to provide additional«ell site details or well
S.Number of wells eonstr izeted: 1 comituctlon details. You may also attach additional pages if necessary.
Far muhlpde 12lrrtkwi or non-comer nq otp+setts ONLY with the mot consowdom boa eym
snrhmir ewe farm. SURM(TTAL INCTUCTIONS
9.Total well depth below land surfaces 25 ((L) 24s. Pbr.All Wells: Submit this foal within 30 days of completion of well
For owhiple wells lin idl dq r 1fd*rem(exmriple-302M'aid 20 100r) construction to the-followiq:
10.Static water le%TI below top of easing: 00 Division of Water Resourtm Information Processing Unit,
If matrs level k above cdstnt,ass"+' 1617 Mall Service Center.1121do.NC 276994617
11.Bnrcbntc diamctcr.2.2 5^ 00 24b.For in j&lln Wells ONLY: In addition to sending The form to the address in
24e above.also subinii a copy of this form within 30 days of completion of Wc11
12.Well construaion method: DPT contraction to the following:
(i.e.augur,ratan•,cable.dirm push etc.)
ph4sion of Water Rcsottt•ms.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh.NC 376"4636
13a.Yidd(gpm) Method of test: 24c.For Water Sutmiw&injection'Wells:
Also s ibinit one c W of this form Within 30 daysof completion of
13b.Disinfection"e.. __ __ Amount: well construction to the county health department of the candy where
constructed
Form GW-1 Nonh Carolina Dgwwrnt of EmiArmsent and Narural Rewumcs-Dh ision of Water Re5outm Revised August 2013