GW1-2022-03375_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD
For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
Oliver Pederson 141.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 12 11- 64 ft. Below water table
4481-A ft. I f3.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased NMls OR LINER if a linable
FROM 'rO DIAMETER THICKNESS M.41'ERL41.
Cascade Drilling, L.P. 0 tt. 54 ft. 2" sch 40 1 PVC
Company Name 16.INNER CASING OR TURING(geothermal closed-loop)
USACE-FUDS Site FROM TO DIAMFTER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable hell pennies(i.e.CnunlP.State,I ariance,btlec•tion.etc,)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal-Public 54 ft. 64 '° 2 .010 Sch 40 PVC
❑Geothermal(Heatiu b-Cooling Supply) ❑Residential Water SuPPI)(single) f. in.
❑Ind ustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑[rri,ation 1 ft 48 fL Portland Tremmie Grout
Mono coin-Water Supply Well: 48 ft• 52 ft. Bentohite Tremmie
�'Moni tori ng ❑Rt:•coven�
Injection Well: ft. R.
OAquiferRecharge ❑GrottndwaterRemedlation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery' ❑Salinity Farrier 52 ft• 65 ft• GP#2 Sand Tremmie
❑Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑l'racer FROM TO DESCRIPTION lcolor,hardness,soil/rock type, rain size,etc.)
❑Geothermal(I-leating.'Cooling Return) 00ther(explain under=21 Remarks) 0 f` 2 concrete and loose gravel
4.Date W'cll(s)Completed: 2/15/22 Well ID# MW-50T 2 " 4 r` red sand fill material
4 ft• 9 f` red/black sandy silt
5a.well Location: 9 ft• 22 ff• brown/yellow silty sand
Charlotte Army Missile Plant 22 ft. 28 ft• stiff silty sand pale brown
Facility-'Owner Name FacilitylD--'(ifapplicable) 28 ft. 48 It. @28' clay -then white silty sand
1776 Stateville Ave, Charlotte, NC 28206 48 ft. 65 ft. dark brown sand -.rock @ 65'
Phvsical Address.City.and Zip 21.REMARKS
Mecklenburg
Countv Parcel Identification No (PIN) MAR 14 202
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(tfsyell field one lat/lonU is sufficient)
35°14'54" N 80049'56" W 2/17/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): XPermanent or []Temporary B) signing this Jium, 1 herchv con jy that the a ell(y tra.c/tram)constructed tit tic vtrdance
frith I SA AV­!('02('.0/11U or 15A Ak A( 1)2('.0200 Well and that a
7.Is this a repair to an existing well: 01'es or XNo copy of this re'curd has been prowled to Me trell owner.
r.//this is a reput Jill mil knownr tell ConslraCOan e n ntjorntaiton and explain thature t flhe .
repair totder-'I remarks seol I or oft the hark o1 this,lortn. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For noduple injection or non-motersupply a ellc ONLY frith the same construction.inn can
submit one j>rtn. SUBMITTAL INSTUCTIONS
9.*Total well depth below land surface: 64' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdliple•trelf,list all depth.,if(htlerew(example-Vie 200'and 7 a100') construction to the following:
10.Static water level below top of casing: 12' (ft.) Division of Water Resources,Information Processing Unit,
lJ'tvafer letrl is ahore racing,u.ce" 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Compact Sonic Rig construction to the followin_:
(te auger-rotary,cable,direct posh,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) Method of test: 24c.For Water Supply d Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Diriston of Water Resources Revised August 2011