GW1-2022-07511_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 1a.CATER WNEs"-
Well Contractor Name FROM TO DESCRIMION
2725-A R EE E 1 E 27 rr 30 ft- saprolite
NC Well Contractor Certification Number 15.QUTER CASING(for rtiiilb cased ipells OR-LINER(if a' [cable)_a
(� r,.
IETAUG ! IL202Z FROM TO DIAMETER THICKNESS MATERIAL
ft. rt. In.Company Name
IfTjti.r irfi�wt�I PT" �UM MANNER CASINGOR TUBIPIG' othermal do-sed-loo
2.Well Construction Permit#:
3cCt$013 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counny,State, l'ariance,etc.) 0 ft 15 rt. 4 "` Sch40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _`'_ . . -•
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaL,Public 15 rL 30 rt• 4 in' 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial 13Residential Water Supply(shared) 18 GRt?UT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring BRecovery 2.5 ft- 11 ft. neat cement pour
Injection Well:
Aquifer Recharge ® applicable)
Remedistion 11 rf 13 ft- be pplica a pour through augers
19.3A11_TD/GRAYLrL;1?r).CK::if ' lirui¢le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 13 ft- 30 ft- #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer RGeothermal
(Heatin Coolie Return) DOther(explain under 921 Remark FROM TO DESCRIPTION(color,hardness,soil/rock e, roin size,etc.)) Tt. ft-
See Consultant's log
4.Date Well(s)Completed:6/7/2022 Well ID#RW 6
5a.Well Location:
Charlotte Douglas Int'I Airport
Faci"ty/Owner Name Facility ID#(if applicable) ft ft.
Airport Drive, Charlotte 28208 rt. ft.
Physical Address,City,and Zip ft ft.
Mecklenburg 21•REMARKS'~�
County Parcel Identification No.(PIN) Well vaults te be by anetheF eent
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 12 31.78 N 80 55 46.78 A,
� 7/8/2022
6.Is(are)the well(s)Ox Permanent or E3Temporary Siunatuie of Ce fed Well Contractor Date
By signing this f ttm,I hereby certij that the well(s)it-as(were)constmcted in accordance
7.Is this a repair to an existing well: []Yes or X)No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 ll'all Construction Standards and that a
If this is a repair,fill out known well constriction information and explain the natar of the copy of this record has been pn vided to'ithe well owner.
repair under 421 remarks section or on the back of this fomt
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 heeded. 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: 30 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:27 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: 10.25 (in.) 24b. For Infection Wells: fit addition to sending the form to the address in 24a
a Auger above,also submit one copy of this form within 30 days of completion of well
12. uger,construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) co
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 636
i
13a.Yield(gpm) Method of test: 24c.For Water Supply& Infection 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 to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016