GW1--03750_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For tricnall Use ONLY:
This Conran be freed for single or muldpk resits
1.Well.Contractor Ltformation:
M AVATER ZON FS
Zach Thompson _ MOM r0 DFSCRtmOY
Well Commaortlamc ft. ft,
4478A
ti fL �
NC Well CorninclorCanifimntion Ntuther IF,OUTE,R CASING ifos-emtti�c 4duccl7s)OR LIFTER(if'a' ©sabre
FRONT 7I) TiMSETER TFIiCdt dE5S MATEPiAL
SAEDACCO Inc 0 rt. 20 rL 2" JIL I SCE-40 . PVC
Congrtmy Nai n; 16.INNER CASING OR:TUBING geodbermal closed-loop
FROM TO DUMETER THICKNESS MATMUL
2.Welt Construedon Pefluit#: R. rs ire,
1.isr rift rpptlii-nhfc u��ll prrnaita fr-e.County.Strttc,Unriartrr.Ir�em�cite J
rt, ft. in
3.Well Use(cIteck well use): 17.SCREEN
WaterSupptc Well- FROM TO MAM TF,R Sr.OTSM '"UMI S I MATRRNAt.
❑Agrkultutal ❑NfunicipaliPublic 20 ft. 30 % 2" ln. 010 SCH-40 PVC
13Geodwtu tat(Heitin'Cooting Suppty) ®Residential Water Supply(single) rL fL in,
®hidustriallCor mtercial OResidential Water Stipply(slated) t9:GROUT ...
FROM TO JfATER141, EAIPLAGEMENTMErnOMAN10tIW
❑Irri lion 0 ft. 12 ft. Portland Injection
Noti:VFater Supply Well;
Mmonitozing Q11ckot-cry• ft. k
Injection Well: ft. (L
❑AquufcTRcclarge. AGiroundmacrRcowdiation 19:SANDIGRAVEL-PACKfit dicabtel'
FROAt TO NLLTrMAI. EMPrA(-l`-M.NTMMr10n
❑AO.niRr Storagc and Rworcy l7Salinity 13arrict 18 R. 30 ft. Filter Sand #2
❑AquffcrTcst ❑Storms-atcr i)tainig;
ft. ft.
❑'ExpCrimcntal Tcchnology ❑Subsidericr Control.
20. tree DRILLiNG'MG fanach additional streets if wecssur
❑Geotliemtal Closed Loop) ❑Tracer FRONT TO DESCRIPTION(mbnFardnyn.xdYtnektr x. 'n`e.de.)
❑Ch mtiletmal(Eleatingfoolirla Relum) ❑011uer(e.\Plairtudder AZI Rewalls) o tL 30 rl Silty Clay -
ft.
4.Date Wells)Camplefed: 5/3/2023. Wdl gD#MW-53S
rt. ft.
54. Yell Location: ry ft J U N .r
Former Charlotte Army Missile Plant ft. ft
FaciilkoDi ocrNanuc Facility IDN(ifapplkable) ;
300 Camp Rd., Charlotte, NC, 28206 ft ft.
Pigsic d Address.City.and Zip 21L REMUMS'
Mecklenburg Bentonite seal from 12-181
CaaWy Mn-el Wnlirtc;IllonNo.(PIN)
5b.Latitude and I.ongttude in derm4minutcs1seetinds ordecimil degrees 22.Certifecad0n:
(Ifnell field,war-l;W10g'gis%%mckla)
35.2442 n -80.8336 w /fL�yY1 -9�L 5/7/2023
gmturcofCcaifucdWei Caurnctar Date
6.Is(arc)theweil(s): %Permanent or. OTemporary 11y:signing&Lr form.I herrbr terrify that the u•rll(s')uvr(min)wayrrucied fir aveorrLmre
with 15A NCAC 02C,010e3 ar NSA rYCAC 02C,0200 Ir ell C6nslrtctiat S(arkitirds irtid i?Ar a
7.16-this a repair to an esistfngwell: Mes or ENo egn-of(My record hnsfa-ctr pmriekd r,?the wr1i(ooter.
rfrhfs'is n tip air,fill mat latouvI will corn-ttucctian brforrnrrlott and ctnlaht rFo rterare of the
reMirarrdcr921 mnarkr.%c[an aran die bark ofthis•ferns 23.Site diagrath or additional well defaiLK:
You may use the back ofthis page to pro%ide additional wen site details or well
8.Numberof wells coustneeted: 1 construction details.You R1av also attach additional pages if Accessary.
For rtrtrirlple Irderrinn or am-!tour supply wells ONLY midi die satne constrr don,you can
sahatlr are four. S RNIL i TA .iNST.T .TiONS
9.Total well depth belolr land surface. 30 (ib;) 24a. For All Wells: Submit this fann within 30 days of completion of well
For multiple ivells list tell depths lfd{Cerew&x4mpte-8Q:00'wpl 2®l0lt'p construction to t11c fotlov in,;
10.Static water level below tap of casing: A) Divisiun of`Pater Resources,Infffrmatian Processing Unit,
if itwor level is above cusing,rise 1617 MaU.Sen•ice Center,Raleigh,NC•27699-1617
I.I.Borehole diameter,6" On.) tab.1!'nr 19fagan Ref19 ONLY: in addition to sending tlx:fomt to the address in
244 above,also subtuit a copy of this fatal within 30 days of completion of well
12.Weil constmetion Rmthod:Sonic construction to die following.
(i.e.augm story.cable.direct posts ctc.)
Divislaa of Water Resources,Underground Injeeflon Control Prot arts,
FOR WATER SUPPLY WELLS ONLY: 1636 Hall Service Center;Raleigh,vC 27699-I636
13a Yield(gpm) 141ef11od of test: 24c.For Ratcr Saltply k' injection Wails:
Also submit one cop51 of this foini ttithin 30 days of completion of
13b.Dkinfation type: Amount: well construction to the corms alth department of the county where
constructed.
Form G1N'-I Nonh Carolhia Deparmwnrof Enviromrwtu and.Natural Resources—Dii'ii1on of AlatcrResou Rcyised August*ll 13