GW1--03743_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For tram]UseONLY:
This form can be used for single or muitipk wells
l.Well.Contractor Information:
t.a:WATER ZONES
Zach Thompson FROM TO 1)"CRIMON
WWlCornractorNatm
4478A
NC Well Contractor Ccniftcation Nurnber 15.OUTER CASING Mir r aulrlised'"crlsl OR LiNER rtf a ca6k
EnOM To DTAdtEiER 7111CKP2f 'tl\ lItAL
SAEDACCO Inc 0 ft. 15 fL 2" ia.. SCE-40 I PVC
ConVany Nana: M INNER CASING OR TrlBING kmtherns2l clakd-loop)
FRONT 70 DUNIETER Tf1ICELNESS MATERUL
2.Well Construe don Permit#: ft. R: �
List all amliraNe 14PUpfrriefts O_d.CounrV,,Shirr,:a$rlamcr.Inftidarl CL7.J
rt, ft. in
3.We[l Usc(check well.Dse): 17:sCRYEN
Water Supply Weth GR0s1 lO DrAsrF.TRR S[.OTS17E T11tC1:NVzSS 'rATRRIA1,
OAgriculntrai t7NiunicipallPrtllliC 15 R. 25 R O10 SCH-40 PVC. .2" in
Meothemlal(Heatirig,'Cooling Supply) ®Residential Water Supply(single) fL %
®lndusuial/Conlnictcial ®Residential Water Supply(shared) I&GROUT
FROM TO HATERML r%[PLACEMENTMEffiOD&AMOUNT
❑Irrf :ttion 0 ft. 8 (L Portland Injection
Non-Vi°ater Supply Well:
10,10nitoeing . ORecocery ft
Injection Welt: tt, tt
❑Aquifer Rcchii%d l7GioundvsulcrRcutcdialion t9:SANDIG EL PACK(ifapplicable);
'FRO\1 TO MATPRCAL RMPr.ACEtIENTMET11011
❑Aquikr5iorage and Recovcry OS,tlinityl3ariter 13 R. 25 ft, Filter Sand #2
OAgtlifer-Tcst O5lorrntitltcr Dr,.0Magc
❑ENperimcntal Tcchnotogy OSubsidencc Control
10;DRILLiL1G LOG(attach additional sheets if necessan•1
Meothentud(Closed Loop) ❑Tracer .FROM TO DExCRIPTION'fi»Mr.hnNnca,saa'mektr. 'n-re.dr.1
OGeothennal(HeatiuglCooling Return) ElOther(explain under#21 Remarks) 0 fL 25 ft, Brown silty clay
fL fL
4.Date We[I(s)Carnpleacd: 5/10/2023 WellmdHEI-06-07R
ft. ft.
(-- --; '73
t
54.%VdI Grc Itinu: fL tL s �'
Former Charlotte Army Missile Plant ft. ft. t dd
Facifft Name Facility lDk(ifappliclble) ft. FL
300 Camp Rd., Charlotte, NC, 28206 ft. ft. rti,.ra+�
Physkal Address,City.and Zip
'•2 L REflrARh.S
Mecklenburg Bentonite seal from 8-13'
Cttpnly IArvel IJ:'nlirrcation No,(PIN)
Sb.If atitudc and 1<vngitudc in ticgrculminutuliccondsfir decimal dcgl•ecs: 22.Certification:
(lr�.�lt rcld,rnk I:w'loag is arfiiciCrrl)
35.2462 N -80.8331 VV r,��-y/- � 5/15/2023
gruaturc of Ceitificd Welf/Contractor Dale
6.TS(are)1hC aYeli(S): SlFetrmauent or L7Temporliy lly.slgninb this famr,.1 hereby eerfify char rite rVellfsJ nvs(nrrvl c,<•winfeterl f t a eordancte
win)15A XCAC 92C.010)or 15A NCAC 0MtiM0 Well Consirrrcrlan Sfarxlards olrcl rhar a
7.Is this a repair to an exktin t;well: CIV'�w or NNn rafirafdifs rernrrf hastrrtt prarirkd rartir in*11 mr�u r.
if this h.a Irmir,fill oat kviAwt ire(!caruttrierlarrbrfamurrlatr art+!ecplaht the turntre of rfie
repaframlcr#21 rrararks• vi thin or wr Me bark of'thh fans. 23.Site diagram or uddidanat well detaiti:
You pray use tltc back of this page to provide additional well site details or treil
8.number of wells constructed: 1 construction details. You may Aw attach additional pabvs if necessary.
Fur rnnld*Jr?A-crhm ar atxr-nti7ter supply wells ONLY ndrh the saute carrsfrurtlarr.you can R iBiVi[TTA .IN,
t T .PIONS
xal xnlf ane form. _
9.Total well depth below land surface: 25 (p,) 24a. liar Alt Well-, Suhutit this faint within 30 dmvs of comp[eaion of well
For ranlrlple wells llsr all depths if differens eorw irk-3@2ffr atwl MOW)' construction to the folianing:
I(J.Static water level below top of casiuX A) Division of VF'at&R6aurces,Information Prucessing Unit,
lfituter level!s cbave main,;,ase"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25" (ia) 24h.Err Bl[ectian Welra ONLY: In addition to sending the fo nt to the addrm in
24a above.also submit a copy of tins form within 30 day's'of completion of well
12,Well construction method:HSA c'ansImCtiml to the fol OM112.
(Le.auger.rotary cable dimx push.cta:)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i636 MIA Service Center.Raleigh,NC 27699-1636
G3,a Yield Wm) hfcttuad of cut: 24c.For.W:ltcr. Sa 1&s.k l[Nectiort WcM:
Also submit one copy of this furor,within 30 days ofconlpletionof
13h.Disinfection 4lier Amount- well construction to the caunn,hCalth dcpallment of the comlh•aehcln
constnlctcd. �
Farm GW-L Nonh Carolina Dclxutnlcm of Em•iratmrim and Natural Resaruces—Division of Water Rm rotes Revised August-V13