GW1--03745_Well Construction - GW1_20230602

�VELL CONsTRUC'CION RECORD For tnictral Use bNLY:
This form can be used far single or tnultipk wells
1.Well Contractor Information:
'Id:AVATLR'ZONES
Zach Thompson FROM TO OF-KRIPt7ON
wdlConlm clot Nam
4478A
NC Well CorametarCcnificationNunber t5,OUTER CASING ORLINERrd.10 fleirhk
FROM ltr DF4attTER MCKMESS \lATEnFAL
SAEDACCO Inc ft. ft.
Conq+:ul}•Name M INNER'CASING OR TiIBING ewhermal clasedaoa e
FROM lm -F-Dwvu:T—rR--1 THICKNESS I M4TERML
2.Well Construction PCITult#-. 0 R. 42 ft: 2" SCH-40 PVC
�isrnllnjyrfira6fr.x,'Npsrririts air.Carroty,Stare,lrnrin+rce,Ir�a'Daq,•1�-.)
ft, ft. ur
3.WCII Uso(CIMOCWCll use): t7:St'itiisN
Water Supply Welft FROM TO DrAMETER SLOTSvx THIMMSS I MATKRFAI,
CIAgFi,-t►i[alral Ci]GtunicipaVPyblic 42 ft. 47 ft. 2- im 010 SCH-40 PVC
Meoiltermal(Head Coon g S t•} ®Residential Water Su (L 2 in,
�' � uPP} PPl}'(single)
C ludustrial(Conmtelcial ©Rcsidential Water Supply(shatrd) IS.-GROUT
To arATEntAL e+teucefrBNr MerneD fi Ahlouivr
❑rtri Rtion 0 ft. 35 fL Portland Injection
Ntln-Water Supply Weff:
rt. rl,
MMonitoring E]Rccoyery
Injection Wett: ft." rL
0AgnifcrRcctrarga QGroundvwttcr Rcmcdiarion M SANDIGILI;VEL PACK(ifa r Ilical)NI-
'FnUM TO MA'rantt1, tthip1.A(.M.NTHFTnOn
❑AgnifcrStorageaalltccaF•cr}' ❑5alinityl3arrict 4o R. 47 ft. Filter Sand #2
❑Aquifcr-Test ❑SlonnwatcrVrunig:
❑Expctimcnial Tcehnvtogy 081thsidencc Control
20:DRILL111GlAM(attach additional sheets if nccessar
OGeodlettuul(CloseefGoop} ❑Tracer FROM TO DFSCRIPTFONk»bnlmrdncawR'nakt, nare.aua
Meotheimat(HeatingrCooliu Return} l7Ottter(explaitt under 421Retuatls) a ft. 47 ft, Brown silty clay
fL ft.4.DateWell(s)CampMed: 5/9/2 0 2 3 WelliD#COEMW-22R
$a,Well L IC4tiem: ft. fL 1
Former Charlotte Army Missile Plant ft. fl.
FacilitpOwner Nam Facility IDR(i(Tappli able) R, R. , -s'' "' F
300 Camp Rd., Charlotte, NC, 28206 R, ft
Ph}-si Al Address City.and Zip ="2t:REMARKS
Mecklenburg Bentonite seal from 35-40'
(kn+Wa' Pircel ld.rdiriGalipu No.(PIN)
5b,Latitude and Longitude in dcgrcesiminutestscco,nds or decimal dcows: 2L Certilleatioa:
(1f,�al meld,pry r;ttloug 1a srrinckw)
35.2471 N -80.8321 F`j //L9�17i 5/15/2023
nruirc areeitir>rn we Catutactor Date
6.is(are)the wcll(s)t MPennaneat or OTemporat7r
B,•signing tlydr farm,1 hereby eenrije thru the nrll{s!was(,srn)ccvn7ructed fir rrccoxlmrre
it-PA 15,4 NCAC 02C d11a9 or 1 sit NCAC 02C.02M lVell Cons[recdarr 8farrdards and rlxrr a
7.Is this a repair to an existing Well: C]Yes or MNo. entryofthh necooihas N;cn provided to ihr urll mrner.
if this is a re�rlr,fill ontkrloµvl nrrt!c�rx,7nr�rfaa i+tforrnrrlwr err+;l rspfaln rlw nrrn,re ojdre
rc�mir reridcr�?1 rcmierks srcidan ar cm dm brisk njUrrs jornr. 23.Site diagram or additional Well details:
You may use the back of this page to provide additional well site details or%veil
8.Number of Wells couNIMLted: 1 couslructiou details. You may also attach additional pages if necessary.
For rnnlrlple.lgferrlon or ntur-rrvtrer supph.wells ONLI'n'hh the srrrrre coasrrarrinu,you ern
sabu+irone furs. S iBM1fITTA .iNST T -TiONS
9.Total welt depth betmvland surface. 47 (tl,.) 24a. Fbr All %VcHi Suhndt rids form within 30 dAys;of completion of well
For+naldple wells Hsi all eepN.s firilfferew(ex rapfe=3@2(l't7'nrut 2@ IM) construction to the folloniog:
flu.Static pater level belaw top of casing ((Ii,) Division of Water Renoir rces,.1affi rMatian Prucessing,"Unit,
if imwe-level is&,ove casino,am"+" 1617 Malt Service Center,Raleigh,NC 27659-1617
11.Borchotc diametcn 6. (in) tab.For 1nI[r9on Weily ONLY: in addition to sending(k form to the address in
24a abom also submit a copy of this forts withitt 30 da}'s of completion of Well
12.Well construction method: Sonic crotutructiotl to the€allowing:
(ic,auger.roar ,cnbla detect puslL etc.) Division of Water Resources,Underground Injection Control Program,
FOR NVATER SUPPLY WELLS ONLY: 1636 Mill Service Center.Raleigh,NC 2 7699-1636
13a,Vicld(gym} hlctitad of test 21c.For watcr supnlF&tdcctioa Wells:
Also submit one cop), of this form;tsithiu SO daps of completion of
13h.Disinfcctiun typet Amount- w'Cti construction to the county health dcpailmcn(of the c[nrrlty where
cvnstntctcd.
FanuGfV-1 North CarallnaMzpcmnamofEmiroamcat and NaturalRcsources-Divi;ionofRreicr-RL- r Re sed_tygust-N?1.1