GW1--04182_Well Construction - GW1_20230706

WELL CONSTRUCTION•RECORD For Internal Usc ONLY:.
This Form can he used for single or milt ink!sells ci
1.R'cll.Contr actor Information: ,t `l
• t4:.WATER'ZONFS
John Eiseman F14051 "TO t DESCRIPTION
Buell CotArvctor lq:,-ane It. rt. 1
4439 ft. ft
NC Well Contractor Certification Nunllcr -.15;:OtlTER CASING(f rrinulti�ciiseil ni:115l.OR L1NERtlf an'kabki', ...
FROM ' To ' PtAMETeln THICKNESS • MATERIAL
SAEDACCO Inc (I. f4 to
Company Name. •
ItIONNER CASING OR TUB ING.(tcvilreimrt"eloW-lo ii ;- . .
• FROM TO - DL METER TUICKNISS • MATERIAL
2.WcU'Constructisn Permit is 0- R. 18 Ft. 2" • l, SCH-40 PVC
LEFT uII applicable well prnrits(ix.Coomfy.Stale,Variative,!real err.)• • ft ft. In ,
3,Welt use(cited.w•cf use): •
27.SCRLSN . •
•
Water Supply Well: - - FROM r TO nitMETER St.OTSin,, 1111(1 Nns I MATRR1A1.
•DAgricultural l iMimicipaliPttblie• 18 ft. 23 ft. 2r in. .010 sex-90 PVC
©Geothemtal(Iieating)Caoling Supply) DResidentiai Beater Supply(single) • fi. ft in,
ndustri:tllContniercial OResideutial dicer Supply(shared) tt:GROUT
D --
FR051. ••70. ►t,ATERrAL EMPLACESIESIT METHOD C ASIOUNT •
. - Dkrigation . . - . 0 ft. 15 rt. Aqua Guard Pour '
Non-Water Supply�Feir: rt ft.
DMonitoring . DReiagvcty • - -.
Injection Well: ft. 'rt.
°AgttiferRcchar'e bdQiouridwttcrRciucdiatian .L9:SAND/GRAY LPACKtifanitliatihtay'- .- - -- - -
FROtf To • 5I&T7:R1.41, r<sIPLM;IAIISTMrallni •
DAijnifcr-Storage and Rcvo%e,ry I]Salinity Barrier 17 R.• 23 rt. Sand #2
❑Aquifer Test ❑Stomm;ltcr lhnit(agc f6. It. •
CDE:cperinicnialTechnologv DSRbsidcncc:Control
20 ORILLING'LOG7altoch•addltioiiiitl sticets�if neccssnrl•l '
DGeodtetnml(Closed Lump) .DTnicer From . TO DrSCtttrries wear.burdrw++,It it nnk l iv„-er is silo.tern)
DGecotheimal(Fleatine Coollog Rclum) DOther(explain under l)21 Retualks) 0 - .ft. 23 ft, Silt/sand/clay
It: ft.
4.Date Well(s)Completed: 6-16-23 *ell n)#SW-3 .
'ft, ft.
5a.Well Location:. .ft. ft, ^? :, r•�
Charlotte Army Missile Plant it. 11, t"r" a )"s �-•
FacilityADn•nerNatne Facility 1D4(i1applbable),
R, n, JIJ! 06 2023
1820 Statesville ,Ave., Charlotte, NC, 28206 . ft. ft,.
Plusi^ulAddiess_City-aildtip Inc":=1-: ,:i,9 Tar"--s: Jut:; •
p
Mecklenburg gg bentonite seal installed from 15=T'/c- -"
.
Ccmuh• twat ldemlifeidouNo:(PIV) I
•
Sh.Latitude antiLongintde in degrees/minutes/seconds nr decimal degrees: 22.Ccrtifca6Oa• '
(it oaf r,c)a,rare brt,lqug i i tidti d) . ..
i1 w r � ,- -- --— 6/18/2023
Signoras o/f.,"rN� nt r:..!.A.f ini.�Mi;;.---- Li-ale
6.is(art.)the lvelt(s)r %TPenn:meta or DTeinporary 11r Si,Cniaiij stir false*r :IIY.C; ih :rh S J�j"•�.r, rnrsfrirrrexl ter rtxonlrznix
U'OII/5,1 airCLC 02C.''-'-.1.7;'C.%..u.c 0.2200 Well Corrsrrtrtimr Srrndards and fix:a
7.Is this arePairtoancustint;Wells DYes or itilNo 'eerpi•,nf this recordldri'Ellyn pr»rirledrri,the%mirirrrier.
Ifilris:it n r:palr,fi)1ec,rDevine writ amin ct(eta)rtrorvrrr:rtoir sine!4/ntn Mt'newer,of the
repair ruder ai2l rernarkssecttua ar in the bark of this form. -23.Site_diagram or addltionut.well details:
You may use the back of this page to)ftovride'additional well Site.details or Well
' 8.Number of wells constructed: 1 •constructloudelails. You inag also attach;idditional pages if t>L•cessaiy.
For malrlpk ldeerlon ar nor-wirer supp.t wefts ONLY whir die saute costsfedetior,yin rvv1
s:r(raritc*form. SUBMITTAL INSTUCTiONS 9.Total Well depth helotv land surface: 23 • • (ft.) 24a. For ALL Wells: Submit this form within 3U )Lays of cotuplciiou of well .
For nralrlple.se ells itsr all dcpabsifdlf•rearlerample-3@300'anrk2@slttl9 'construction to the following:
1l.Static water[del below top of easing: • (ty,) Division of Water Resources,Information Processing Unit,,
ifuahv 1et,e1 is am antral?,siral?,in.!!"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehcile diameter 8.25". (in.) tali.For bilett(on Wells ONLY: yin addition to•sending the Corm to the address in
24a abot•e. also submit a•copy of this four[ within 30 days of completion of hell
12.Well consttvetion method:'ESA • •constriction to the fbllowinet: ,.
(i.e.auger,rotary,cable,direct gush CO
. Divisions of Water ResOurees,'Underground Injection Control Prngraul,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
• 13; k'icld 24c.For Water Snooty&Injection.Wells:
k (gfm) ',Method of test:
Also submit one Copy of this forin within 30;days of completion of
well coitsttioF to the
13h.Disinfection type: Amount: well county health department of the county when:
constructed. I
FonnGW-L Nash Corolla Depannt nt.of Environment and Natural Resources-Dlyision of Water itesourcm fievised,))rota)2013