GW1-2021-08036_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD rat trtemnl Use ONLY:
This form can W ascd for sin&or mull ipk ucils
1.Well Contractor information:
14.WATBit ZoNts
Brian Ewing FROM TO ore tP`Osl
tt'e11 Contractor Namc R.
4240 B
ft. f4
NC Well Cotnrmar CCnifmalion Number J&O[fM CASMOtar troth arsed vir6ls OR t b
FROM TO PIAMTMR THICKNESS I MATENTAL
3AEDACCO Inc 0 (. 43 R. 2.25" in. NA STEEL
(.wiWaityName 161TtivEl2C,LS7 GA1)RJVB1N0 thtvrirateltsricd
FROM I TO I DMIMETER I T111CT IS4 I MAUML
2.Well Construction Permit#: R. ft. a►
ldst all amlimsble swa permits(i e.Gounn•,Starr.Varia"tr.Itfta den err..)
3.Well Use(chedcwell ose): t7:Sf;e10EN
Water Suppl}Well: FROM TO I atAMFTP,R I Si StxF I T111t,M_ I MATRNTAI,
CAiiricultural DMunicipatlift is 43 fL 47 (L 1.25^ K -004 NA STEEL
DGeothermal OicatifWXboling Supply) DResidential Water Supply(single) ft. m IIn
Dlndustrial/Cormuc cial 01tesidential Water Supply(shamd) 18"CRO
FROM 1 TO MATERUi, EMPIACPMENT MMOD&AMOUNT
Oho tiara R R.
Non-Water So"Well:
®Monitorin ❑Roco%x th ft
injection well: n. rL
❑AquiferRccharge DGmuldnaterRenrcdiation It.S DIGRA LPAIM
❑AuifcrStonlge and RccoNicty ❑Salinih,Barrier PROM tAT un RMPIA("_l4MM"1HlOn
R. R.
❑Aquifer Test ❑Stornmater Drainage
R. t4
❑ExperimcnialT=hnology 051fisi&-I=Corkml
74.DRBddi►G-Lt}l3 at"=sdAlltonat eaters Knecessartil
❑Gootbemwl(Closed Loop) ❑Tracer FROM TO nPS(IITFTtO�tabr.asNn ioEhecR ek.)
❑Geothermal(Heath ooli Remm) DOther lain under#21 Remarks) 0 (L 25 R. FILL SILT AND SAND
25 R. 47 fL SILT WET PWR
4.Date Well(s)Completed: 9-23-21 Wdl1D#GW-0lA
R. fL
S L Well L(1eat•Ioa: fL IL
Former Charlotte Army Missile Plant fL (L r __
Feclit)m"mrName Facility iN(iragpiitarblc)
IL et.
1824 Statesville Avenue, Charlotte, NC, 28206 R. p,
Phsskd Address.City.and Zip 21.REM
Mecklenburg WATER SAMPLE W/SP-22 �(1{J p,)OCFSSING U ll
t,aunh Parcel idealifieation No.(PIN)
5b.Latitude and Longitude in degrecr4mirmtWscconds or decimal degrees: 22.Ccrtifecatlon•
(ifgeil field,vale I w1oi it srdtieite8)
W Bran Ewir ,g.�. 10/13/2021
�_.
si�ntum oreenifsed well Canuacwr Da�c
6.is(are)the wtil(s): OPermanent or zTernporary AN signing this farm,1 hereby r4errify(hat the url4s)war fwrrei rwalmrred in aroonMnc'r
with 1 SA NCAC 02C,0107 or 15A NCAC 02C.020f)Well Crnorwrie r Smrdimts mid chat o
7.Li this a repair to an existing well: Oyes or MNo ropy of this rreord has arm pt»eidrd to rhr lull turner.
If ibis ii o irpalr,fill our knaKrt t.`etl rot o t(on lnformtetkn and etpdohr the wavre of fir
repair w der d21 remarks scttian or rat the bwh of this farm. 23.Site diagram or additional well details:
You nu1.,use the back of this page to pro%ide additional%vtll site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if mcessery.
For atu(rlple ioJty'r/4M of trtas•xvsrer supply wrlfi OrtY,y mlrh der same e+oastrartloar,you two
sumatanr fonts. C iB 19"PA .INSTUCTIONS
9.Total a ell depth below land surface: 47 {Ik) 241L Mar AU WelW Submit this form within 30 days of completion of»till
For axit(tiple wetly hAr eflAe hs(f d4Bi rent ft mmp►e-3@200'real 20-1f711') construction to the foitoy0ng;
10.Static water le1r1 below top of casing: (ft.) Division of Water Resoorctxt,laformation Proees,.dna unit,
If muee ki el h&%wt rusttrg,war"+" I617 Mar Sen•ice Center.Raleigh.NC 27699-1617
11.Borehole diameter 2.25^ 21h.For tnfmtlqn ffrils ONLY: in addition to sending the form to the address in
24aabove. also submit a copy of this form within 30 days of completion of utii
12,Well construction method: DPT construction to the following=
(i.e.miger.ratan.cable.direci push ceo.)
Division of Water Rtsaurrrs,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276".1636
13a,Yidd(Apm) Method of test: tic.For Water Sap(r1F&tNection iWclh
Also submit one copy of this form isithin 30 days of completion of
13b.Dtxinfecdon type: Amount: well construction to the county l"Ith department of the country whet
constructed.
Farm GW-I Noith Camllna Dcpattnreru of Ea iranmou atd Nanual Resources-Dixision of Wanci ReSawces Rc%°iced Atlgwt 2013