GW1-2021-08038_Well Construction - GW1_20211122

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WELL CONSTRiUCTION RECORD for incnml Use ONLY:
This form can l usod ror singk or multiple aids
1.Well Gmtmetor Information:
1,C WA'iRttZONIS
Brian Ewing FROM TQ DRS tttrTl4R
%Fell Contrnrtor'Name h, rt.
4240 B rt. tL
NC Well ComrictorCcni6calknNumbcr OU71RiCASrT!1Gr orawllleaatillne I1RL1NF.ft tf ble
FROM TO DiAMITRR TMCKNM MATERIAi.
SAEDACCO Inc 0 IL 43 fL 2.25- it. NA STEEL
CotnpnnyNsm t6.tNMCASMGOR'tUSING(siolk�miltbud4mal,
FROM TO DtAME. R THICK.'r£84 MATERIAL.
2,Well Congruction Permit ti rL rL In.
list ale aW rreblr.u-411 concur(i e..CmrnN State,t ariaare,Itl xUc l err.; ft. h. its.
3.Well Use(check well use):
Water Supply Wdl: FROM To I DIAMETER. I SIA)TSiZIR I '"11M, 1:SS J ,MATRRtAL
13Agricultuml DMunicipal/Pubiic 43 h, 47 ft. 1.25" In. .004 NA STEEL
❑Geothetuml(iieating/Cooling Supply) 011esidential Water Supph•(single) % ft, In
olndustriaUCommcrdal ©Residential Water Supply(shawl) ie.,aROlrr>
FROM 170 MATERIAL I EMYLAV50T MrMQD @ AMOUNT
Obvigotion ft. ft.
Non-Water Supply Well:
mmcmitorin 171teco- R-
Inj on well: ft. h.
DAquiferRccharge OGroundnaicrRcmediation t9:8AND MPA + led
❑Aquifer Storage and Recovery ❑Salinity Harriet M TO tiar RrAt. Rrtrt n tesr rstl n
OAquifcr Test ❑Stprmuwcr On,iaasc
ft. f4
DEWrimcnlal Technology OSubsidcncc Coraml 70 5R141dlcG LOIi atttuM adtthtarroiat oelstt
OGftthenml(Closed Loop) Orraeet FROM TO Ua"WriO)t hbr.bardom toR%*k typt,wah*P-eol:)
OGeotlrermal(HeatiJ Coolie Return) ❑Outer(e3qilain under 021 Remarks) 0 fL 25 fL FILL SILT AND SAND
25 h. 47 h. SILT WET PWR
4.Date Welt(s)Completed: 9-22-21 Wd1jD#GW-06A
h. rL
So.Well Location: h. ff.
Former Charlotte Army Missile Plant fL % _
Facilits'rOuncr Noma FocRity IDO(if applkable) R. to.
1824 Statesville Avenue, Charlotte, NC, 28206 ft. ft
Physical Address-City.and.Zip 31 'ARKS
Mecklenburg WATER SAMPLE W/SP-22 DM-i SECTION.
Coma? Pareet ldenfirlt:ationNo,(PIN) :. + ..! `. tl V i 1
gh.Latitude and Longitude in degrssslmimttca/secrinds or decimal deRmw. 22.Certification:
(iPNctl fkld,are lerloi is ardt)tictit)
r W —Brian'.. --ing. 10/13/2021
Sigtntdw of ccitiikd Weil Contras a Date
6.➢s(are)the well(s): ElPerntiment or ZTemporary gl•tilgning chit jontr.i hrrebv rerly dtW the nvll(a)rvs(we"i ainttnreted in arrordance
mith 1 to NCAC 02C,010.)ar 1 SA NCAC.OaC.0200 n eY Conserve6tui Snnrlard c((Ad Awl a
7.Is this a repair to an t xiWng well- oyes or M No ropy of thk rMonl has hrrrr pn vridM to char nr11 rmmrr.
1f Ats it a reperlr.J 11 ear bim m well rowitt don infonwikoi mad eydain dw raxure of the
rquir tender 021 rmarics sraim or m the barrk ajrhir form. 23.Site diagram or additional well ddalls:
You may use the back of this page to pro%ide additiond well site details or well
S.Number of wells cotistrticted: 1 construction details: You may also attach additional pages if oecemry.
For mWltipir iaJa*m w ann-wvsrer tWppnv werlt 0lY1 Y wirh t1w acme aonstmetim,,ww car, C1lBM[J jAI.fNSTt1C19ONC
AWWit Me from. -
9.Total well depth below land surface: 47 -()ft.) 24s. For Atl Wellw; Stibmil this form within 30 days of completion of well
For nwiriple,w4h lisr ad drluhr t f dWerenr(example-303 Z t•and 2R-100') constnuction to the following:
10.Static water level below top ofcasing: (fY.) Division of Water Resources,Information Protesft Unit,
if wua t kwi is above tvi0it,ate"*" 1617 Mail Service Colter.Ralcilgh,NC 27699-1617
11.Borehole diameter:2.25" ( ) 24b.Ur 111 Wq$�,db ONLY: in:.uMition 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 Well construction method:DPT construction to the following:
(i.e.auPm rotary,cable.direct pesk cic.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raletph.NC 27699-1636
113a.Yield(gpm) Method of teat: 24c.For Water Sualy&incalon Wchla:
Also submit one coin, of this farm Nwithin 30 da)•s of completion of
13b.Dislnfection type- Amount:, wcll consmrction to the wanly hcahjh dcparttnart of the eouniv-where
constructed.
Fortn OW-1 Noob Camlina DopaAnrrm of Emimi nrcia aid Namrsl Rcsoumes-Division of A'sterRmoirm Revd Ate g 2013