GW1-2021-08031_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD For lnttemal Use ONLY.
This torn can be owd"for single or multiple arils
1.Well Contractor Information:
t4.♦tWMAZONES ,
Brian owing PROM TO OKS tvrtON,
NeilContruamNam n. ft.
4240 B
A. R
NC Well CoturaraorCenificationNumbn 1S 0 ING ffer�tvtMbeaaMfir9.tldt;tom T( 8cabk
FROM To PIA-V. R Tn1CKNM MATERiAL
SAEDACCO Inc 0 (L 21 (L 2.25° In. NA STEEL
i
Compto),Nam 1d 1 GORMIN`G `ilkli t6tisedfoo
PROM TO DIA:tiIF.TER TnH71UN A MA7T:RIAL
2.Well Construction Pcrmtt 0: (L 0. hL
lift aft rrppb'lrfbtr reef!prrmitf Pi r.Colrnry,sAwe,Variance.IfiWfitn e1r.) R, h. Ies,
3.WrAlL3se(check well use).- I f.-S RttBN
Water Supply Weil: PROM TO 101ANF7XR t 6rATbIFX: Ttn(WNTS$ I MATFRIAL
OAgtictlttulal l�tV m cipal1publiC 21 R. 25 ft. 1.25. In 004 NA STEEL
CGeothermal(Hea6ngAGooling Supph) ❑Residential Water Supply(single) tt. ti trti
CSlndusttial/Conimerciat tJResidential Water Supply(shared) I&AMO13T >
FROM TO MATERIAL Er PLACE MW M£iHOD R AMOL'\T
❑ini ion
Non:Water Supply Well:
mMonitori OReco�c
Injection ett: n-
❑AquifcrRceharge ❑GroundwPicrRcmcdiation 19.SAND it 1:PACK te,ible
❑Adquiter Storugc and Recotirly ❑$alinity Harrier PRAM TOI MAT1ratAr, aMPI arnse r METH n
tt. ft,
❑AgaifcrTcsl ❑StormwRterDtttinage
❑E. crfinenm1Tcchnology ❑Subsid=cCorrtml
30.DRILU qG arfitcF additional sheels ff♦teens''
❑Geotltenrml(closed Loop? ❑Tr4r2'd FROM TO 91MCRtPrto;• ealsr.Aardfim.w i,*k o Ne:
oGeothemtal(ILeati ooUt Return) ❑()thet(explain wider#21 RempW 0 Ir. 10 fL FILL SILT SAND
10 ft. 15 (L SILTY SAND
4.Date WCU(s)Completed: 10-29-21 WdiIDASSW-GW-15 15 (L 25 (1, MOIST TO WET SILTY SAND
Sa.We11 Location:
Former Charlotte Army Missile Plant fl, fL
FacilityiQu oer Nance Facilih,ID#(ir applicable)
1824 Statesville Avenue, Charlotte, NC, 28206 (L (L
P1nskal Addmss.City.and Zip 2LAntAIM
Mecklenburg SP-22 WATER SAMPLE.
Conmy Pameltdentiric:nion No.(PIN) • sr:: a .n :/}/.C4�,(��' ;,.a;
Sb,l nitade and longitude in dcgrecs/mlmites/kcandsor decimal degrtxs
(it'mett field,one Islort is saftickwj 22 Certfiecatinn:
N W ,Bria.,n.Ewin 11,2,2021
Sigmtew of CeniGcd Wdl Carumctor btu „
6.I9(are)the w'ell(s): oPermanent or MTemporary fh•signing this joem.1 hrre4q,rrrfiA that the ratilf(rl mvx(wrreJ c>r utmeted in aetvy4anee
n4rh I SA NCAC 01C.,010►ear!SA NCAC MC.0200 tYed Carrxrntx;r&m Standards attd that a
7.Is this a repair to.anexi.�well: O es or MNo cap),ofrhiserrordhaasN-mpmr�idetttothr',%W1fwnrr.
If this is a repair,fill oor Anomn well eorwrtfaimn ht onwdaa and rwfain the norNre of the
relwir wderb21 rmnorkv frrnnn or an the hock of Mix form. 23.Site diagram or additional well details:
You niay use the back of this page to pro%de additional cvt11 site details or well
R.Number of wells constructed: 1 construction details. You way also attach additional pages if neeessan=_
For ma#♦late iitWd»r or am-none stgrpft kyflr ONLY»irh the mutt ewatsivtrrtiart.}ua awn
xarhmifone,form. SU�AL 111MU QW
9.Total well depth behm land surfaor. 25 (R.) 24a. For A Wells: Submit this fomr within 30 days of completion of well
For mohiple,wells tin afl rlrrulix(fdiffrtenr(exaanple-3@200'and 10 llKKj') constmi'tion t0 the following:
10.Static water lend below top of casing {it.) Division of Water Rcsourlat,Information Processing UnlL
H°wter level is obrnr casing,use"a" 1617 Mail Sonic Center,Raleigh,NC 27699-1617
11.t3otThok diameter 2.25^ (icy) 24b.For inWifflgn Welly ONLY: inkaddition to sending the form to the address;in
24a above. also submit a copy of this form within 30 days of completion of well
IL Weil oo►Mtrnetion mahod: DPT construction to the following:
(i.c.auger,.totmy,cabin dirad pests cm.)
Dhision of Water Resources,Underground Injection Control Program,
FOR WATERSVPPLY WEL.IS ONLY: 1636 Mail Service Cemer,Raleigh,NI C 27699.1636
13s,Yidd(gpm) Micthod of teat: 2�e For Water 5R 1 &to octhm Wetiv:
Also submit one copy of this fort within 30 days of completion of
13b.Dtsinfoctinn tvltc Amount: constructed department of the coamt�where
tisctl conStaXlion to the County health
Form GW-1 Nona Carolina Dqartnnom of Ewimnmra and Natrral Resources-Dhision of Rrater Resdirots Rer,rsed Atoa 2013