GW1--03747_Well Construction - GW1_20230602

NULL CONSTRUCTION RECORD For lrtcrnal Use ONLY:
'ibis form can be used for single or uultip)c%veils
1.Nell Contractor Information:
I-:WATER ZONES
Zach Thompson FROM 'to D SCRIPtte)N
%yell Corxr csorNarw
4478A ft. f4
NC Well CamraclorCertiftcation Number 15.OUTER CASING OR LiNER(I1 a' eabk .
FROM TO DiAMETEn TIfiC[+N€S9 hrAMIAL
SAEDACCO Inc 0 (t 1 15 f4 2" in. I SCH-40 PVC
Comp:uly Nang I6.'iNNRR CASING OR Ti1BING keciherm2l closed-loa'
FRONT I TO D-L"IETER THICI NESs MATERUL
2.`Yeti Construction Permit#: R. R, I.
List 411apTr11nable wr11 pemrits 0 r.County,Bove,Ilhriarrcce.1ryexdzn eir..)
3.Welt Use(chco;well use): 17:SCttl!E N
WaterSuppiy Welft FROM To I urAUFTFIt StOTSrsk; T1itCNNR4S I t1,4TERIA1,
Mgticultural ONfunicipal/Public 15 ft. 25 R. 2" io. .010 SCH-40 PVC
❑Geothermal(Head Cootin S lyl EIResidentiat Water Su ft. ft.
R!p' g �P Pply(single)
®htdustrial/Conuticicial ©Residentiat\Niter Stipply(shared) t8'GROUT
FRONT TO MATERIAL E\ISLACENMT MEMOD&A.ti10nNT
❑lni ation 0 f4 8 fL Portland Injection
Nau-Water Supply Well:
®Monitoring ❑Rccovcry ft
Injection Nett: f4 ft.
QAgnifcrRcchtirge 17GtoundwatcrRenicdiation 19.SANDIG(LAYEL PACK(if dicabte)
FrtOhT TO NmTrltrm. RMpI.AI".F:�tE:VT MI:TNQn
11Agnifi;rStoragcandRccovcq 175alinitypariicf 13 R. 25 ft. Filter Sand #2
❑AgnifcrTcst . ❑StonnwotcrClrtinaac R. ft.
❑ Vcrimcatal Tcchnotog• ❑Subsiticrtcc Control
'20.DRILLiNG1043(attach additional stuefs if occcssarvl
OGcuthenual(Closed Loop) []Tracer FROM ITO DmciarnoNranbnMnrdnca sormck0 %de.atel
ElGevdnennal(HeatinglCuoliueRetain) p0dier(qx hainunder921Rematts) ' 0 - (L 25 f4 Brown silty clay
rL
4.Date Wefl(s)Completed: 5/9/2023 WetlEDOHEI-06-0811 -
R. ft. 'y .r �.r k 4 t
54,Well Location: ft'. fL 023
Former Charlotte Army Missile Plant f4 iL
Factlity,'QivncrNanec Facility tDR(ifapplicable)
R. ft. ln(S;,,<
300 Camp Rd., Charlotte, NC, 28206 R. IL
Plr-sf:al Address City.and Zip -21.11ENLkRKS'
Mecklenburg Bentonite seal from 8-131
Csruuly Parcel IderitifaxionNo,(PIN)
m.Iattitude and Longitude in degrees/minutes/seconds or decimal dcgnm : 21.Certifcatioas
66%01 rkid,01re 1010ng is$uIlieklo)
35..2467 N -80.8324 5/15/2023
iamwecafCeit[I9cd}4:c Cantractpr Date
6.Is(are)the well(s): MPermanent or ElTemporary Hr signing tidy famy l here r eerfify char the irellf.0 vivy(Film!)amyfrnered Itr accardanvr
ndtA 15A NCAC 02C,01(kl or 1 Set NCAC 02C.0200 11rell Co1[$trrtrtfal1 Srarrdards tald rlurl a
7.Cr thbi a repair to an esistingwell: E]Ver or \BIND rtln ofdtlr rernvllrrrsln cn(rmriricd rn the in*il minty,
if this is a rrpair,fill wit krrotivr wellcwi mrcdoa lnformarlon and etplaht rrrr ttartue of the
relrafrarrderV-I rmurkvsrcrimr or an the&wk-ofthisform. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or%cell
8.Number of wells cousimued: 1 consimetion details. You may also attach additinta[pub s if ue%assary
For tunldrde Ptkvrh?n or emir-wafer sup#y wells O,A'LY rrldi dir saute cvrtstriri(icur,}ou eau
sabmirww form. SUBMITTAL.[NST I .TIONS
9.Total welt depth beftnv Iand surface. 25 ((t,) 24a. Far ALL Wells; Submit Olds fowl within 30 days of completion of%%rlt
For tnahlplr ivetls list r(rF'cprhs lrrli('efcm(c rtmpi(•-3@200•caul 2@[00) eonsiniction to the foltowing:
10.Static water level below top of casing: ((y,) Division of Water Reaourees,laformatiau Processing Unit,
lfwater loud If above cersiog,ass"+" 1617 Mail Service Center,Itrlcigfr,NC 27699-1617
11,Borehole diameters 6" (in.) 24b.Enr Infeefion Wetly ONLY: in addition to sending ilia form to the address in
24a above-also submit a-copy of this fortu within 34 days'of completion of well
12,Well construction method: Sonic crousime-tion to the following:
(i.e.aagcr.rotary,table direct posh etc:}
Division of%Vater Resources.Underground Injection Control Proe ant,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Semice Center,Raleigh,SIC 27699.1636
Ha.VIM(gpm) 'icdrod of test,• 21c,For-Water Su3e&&Injection Wells:
Also submit one copy of this fot'tu'withilL 50 days ofcompletionor
13h.Disinkctian types Amount: wcll construction to the county health department of llic couettp%vkrc
corr meted.
Fanu GWA Noah Carolina Depcarnat ns of Enviroturc u and Narursl Resources-Division of WaterRetau Revised August 2013