GW1-2022-07517_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
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Mike Tynan 14.AIVATER ZO
Well Contractor Name FROM TO DESCRIPTION
2725-A �`.. �r 9 rt 20 ft. saprolite
rt. ft.
NC Well Contractor Certification Number 15.OUTER WING lrar multi cose ,welts OR LINER ffa icatile
ETF' ura FROM ft 7'O ft DIAMEI�ER tt' THICKNESS MATERIAL
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CompanyName k.A
•t 16.INftER`GASING"OR TUBING isothermal closed-'160
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County State, f/ariance.etc.) 0 ft 5 rt 4 to Seh40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: ':17.St�tEEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipat,Public 5 ft. 20 ft' 4 1n' 0.020 Sch40 PVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft in:
htdustr•ial/Commercial Residential Water Supply shared
PP)( ) :18 GROUT..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery 2.5 ft. 3 ft. neat cement pour
Injection Wen:
3 ft. 4 rL bentonite pour through augers
Aquifer Recharge E)Groundwater Remediation F
I .5ANDIGRA: .: �'AG�Z ifs""lical>lu 4 _ '�a.,*,.•. ,�.a,a�,, .,,, ..._;,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage 4 rL 20 ft- #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGhffiG httatfi':adettronahlheets.if itecessat.
RFROM TO DESCRIPTION color,hardness,soitfrock e, rain size,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) ft ft
See Consultant's log
4.Date Well(s)Completed:6/16/2022 Wen ID#RW-19 ft e.
5a.Well Location: ft. ft.
Charlotte Douglas Intl Airport ft. ft.
Facility/Owner Name Facility IDk(if applicable) ft ft.
Airport Drive, Charlotte 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
Mecklenburg `:21.REMAitxs _
County Parcel Identification No.TlN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 12 26.29 N 80 55 42.98 .1V 7/8/2022
6.Is(are)the well(s)0 Permanent or 13Temporary Siviamre ofce red well Contractor Date
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By signing this form,1 hereby cerhfi that the well(s)was(were)constnreted in accordance
7.Is this a repair to an existing well: [)Yes or E)No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a
If this is a repair,fill out known well construction information and explain the native of the copy of this record has been pawided to the well owner.
repair render 421 remarks section or on the back oj'this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal R'ells 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: 20 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells list all deptlts if dj)yerent(examtple-3@,100'and 2C2a 100) construction to the following:
10.Static water level below top of casing:9 Division of Water ResoEurces,Information Processing Unit,
lj'water level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10.25 (in.) 24b. For Infection Wells: tit addition to sending the form to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,l Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply& Injection Wells: hi 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 io 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