GW1-2021-08023_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD ForirtermluscONLY:
This form can be used far single or mull ipk wells
1.Well Contractor information:
tL WAT1'r.R IONl
Brian Swing IRON To DF tPl1t)1
vVell Cootmdor N?ltne fi. ft.
4240 B
p. h.
NC WeltCoW=or Ccnifiwion Nvr&a t1.aturr�t.CAS1NCr ffor caul-cased*Too,3R Mm b
FROM fD' lAttfr,TE Tir1CK\fS9 MATTRiAL
SABDACCO Inc 0 fL 1 21 fL 2.25" j in. NA STEEL
Cof*wNarre t I CA51NG'OR'7178RiG: eo'tkrm eiascd
FROM TO D1ANIFTEiR T1r MMESS MATERIAL
t Welt Construction Permit#:
feu all applirttbir+cell prrrnitt(i e.Ctmrntr,.Thor.Variorwe.ItfaTian eir:) h. h.
3.Well Use(ebmk well use): 17,SC1tli !
Water Supply Well: TO DIAMETER StA)TSITZ '"11 M TMATMIAl.
OAgficultural ONitinicipatTublic 21 ft, 25 (L 1.25" In. .004 NA STEEL
DGeothemtai(Heating/Cooling Supply) CResidentiiai Water Supply(single) R ft`
0IndustrialtCortuncrcial 01tesidcmial Water Stlpplp(slated) I&GROi T
FROM I TO MATERIAL EXPIACEMM ME MOD&AMOUW,
❑ttti' :ion tL gL
Now-W'atcr Supply Weal: h h
mmonitorin DRcea�e °
Injection Wet: CL rL
DAquifer Recharge 170roundnstcr Rcmatiation t9. ANnIGRAV�t t?Ac e
DAquifcr Storage and Recovery ❑Salinity Barrier Ps M TO 11fATRRfAI, t>a1tPtAt"l1iRVT Mr"TtIOn
h. R.
17 Aquifer Test MStomtnAter Dmirtagc
ORxperimcntalTechnology OStm dcaceCon"I ft. tL
3(Y, RD.L1iKi l�t)ts rtitaciaddiNtma/�lrretslf
13Geothetmial(Closed Loop) DTracer FROM arbr.herdeery rtoazt%*k 0 ot.gWA ttrl
OGectfliemral(Heating/Cooling Return) OOther(otplain under#21 Remarks) 0 fL 10 tL FILL SILT SAND
10 fL 15 ft. SILTY SAND
4.Date Weli(s)Completed: 10-28-21 WdI M#SSw-GW-8 is fL 25 (4 MOIST TO WET SILTY SAND
5a.%Veil Location: ft. ft.
Former Charlotte Army Missile Plant
Facility)Owner Nano Facility TDk(if applimble) � ft a
1824 Statesville Avenue, Charlotte, NC, 28206 fL tL
Pln-skel Address Cith.and Zip ;2L
MMM
Mecklenburg SP-22 STATER SAMPLE. tr ��SEC
Coatm• Pottel identiflealion No.(PIN) t 'r1(;FSStr G j
5b.Latitude and longitude in degmc s/mimrtWscconds or decimal degrvas: 22,Certification:
(if ueiliiietd,are 4ahorg is stink-Ittd)
N W 11,2,2021
5ignstntc of cenifcd W'en conumnor t
6.is(Are)the well(s): 13Permanent or ZTemporarp fit•sig tinx thiss fwm,t herrhr MrWy thug the night sl air(j4v 'l("utovemd in amonk"te
with 1:5A NCAC OX AIiKt or l SA NCAC 01C.0200 Nell Comfewt firm Stnndards and that d
7.Is this a repair to an existing well: Mca or MNo ropy of thin rwonf hos brew pwidrd to Or nrli owwr.
If 0#4 it a repair,fill our Affoom Kell cotwnwflm+htjarrnnrkot4nd ctpfaln Ax notwe of the
rrp"fr wrier d21 rrawrL xft-thn or an flit bt"l mf-this Joan. 23.Site diagram or additional well details:
You may use the back of this page to,provide additional%a site details or well
8.Number of wells corlsttmcted: 1 constmctimt details. You Ina►°also attach additional pages if necessatp.
Fop MM14,114e iojcffkwfd+•omit-r,ttrer°rV#,V,uethONLY14A(he Wmeeo»drla!l1DPr.vat can AubmiloneJorm. �_CBM[7'iAi INSrLCTlONS
9.Total well depth below land surfaces 25 (11.) 24a. for Ali Wells: Subunit this form%thin 30 flays;of cotrrpletion of well
Fnrtnatftlrle n�ftc flat all,frgrJ)r fJdif}ar�,u(fr<mtl�fe-3@ 300`and 2�10(�p construction to the following-
10.Statte neater level below top of castagy (ft,) Division of Water Resourtt&information Processing;Unit,
ff wyner lrvel is aboiY rattop,ow^+" 1617 Mail Senice Center,Raleigh,NC 276"-1617
11.Borehole diameter.2.25" (in-) 24b.For iggjm(nn Rdh ONLY. to addition to sending the fort to the address in
24a aboee. also submit a copy,of this form within 30 days of completion of null
12.Well construction method: DPT construction to the foilotOW
(i.r.awrgAr.ratan•,cable.direct posit etc.)
Dhision of Water Resources,Underground injection Control Program,
FOR WATER SG-P.PLY WELLS ONLY: 1636 Mail St nice Centtr.Raleigh.NC 276"-1636
13a.Yield Qtpm) Method of test: 24c.For Water SuWy&injection Welts:
Also submit one copy of this form within 30 daps of completion of
13b.DhAnfoction type,a Amount: ucil conshuction to the county hcahh department of the county n•hcm
constructed.
Form Gar-1 Nonh Catolim Dgnnmm of Eavironarm and Nnmral Resources-Division of Water Rtsoircl3 Revised August2oll
i