GW1-2022-07509_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan K WATERZONES` ...
We1lContractor Name FROM TO DESCRIPTION
2725-A 9' 26 ft-
28 q: saprolite
NC Well Contractor Certification Number t1�` is.OUTER CASING_for.inulh-case!Lwe0s OR7INER a icable t
IET (s i i �"�Z FROM TO DIAMETER TWCKNESS MATERIAL
1}r� Mfg
F'J ft. �. in.
Company Name
fit+I PTO� 16.-INNER CASING OR TUBING: tn totheral closed-loo
2.Well Construction Permit#: lfl c4m ofaOG FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, 17ariance.etc.) 0 ft• 13 ft' 4 rn Sch40 PVC
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C)Municipal,Public 13 ft. 28 rt. 4 "' 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
hrdusaial/Commercial 13Residential Water Supply(shared) GRUIIT,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&-M4OUNT
Non-Water Supply Well:
Monitoring EIRecovery 2.5 rL 9 f• neat cement pour
Injection Well:
Aquifer Recharge []GroundwaterRemediation 9 n. 11 ft• bentonite pour through augers
19:SANDIGRAf LPAt ,"ifa :iictible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 11 ft- 28 f• #2 silica sand pour through augers
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 2b:DI2I3dTNGhQ(;.att3clundditioilaLhpetsnecessa
FROM TO DESCRIPTION color,hardness,soitfrock e, min size,etc.)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ft. ft.
See Consultant's log
4.Date Well(s)Completed:6/8/2022 Well ID#RW-9 ft. ft.
5a.Well Location: ft. ft.
Charlotte Douglas Int'I Airport ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Airport Drive, Charlotte 28208
Physical Address,City,and Zip ft. ft.
Mecklenburg
County Parcel Identification No.(PIN) We" vaults te be by anethelF eentFaet"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 12 30.72 N 80 55 45.30 W
/ 7/8/2022
6.Is(are)the well(s)ox Permanent or 13Temporary Signature of Cer red Well Contractor Date
By signing this form,I hereby cerhfi•that the wells)was(were)constnucted in accordance
7.Is this a repair to an existing well: 13Yes or XJNo with 15A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constnrcton information and explain the nature of the copy of this record has been provided to�the well owner.
repair tinder#21 remarks section or on the back oJ'ttis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28 (ft-) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii#ererrt(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:26 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
25
11.Borehole diameter: 10. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
au Auger above,also submit one copy of tliis form within 30 days of completion of well
12. 'e construction method: construction to the following:
(i.e.augerr,,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction tb the county health department of the county
where constructed.
Form GIV-1 North Carolina Department of Environmental Quality-Division of 1Vater Resource's Revised 2-22-2016