GW1-2021-07669_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
,
Thomas Whitehead 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft• 11
2907-A IL
NC Well Contractor Certification Number 15.OUTER CING for muRl-cased webs ORR a 8cable
FROM DIAMETER MATERIAL -
S&ME Inc ft. fL to
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loo
WM0301152FROM To DIAMETER 7HICKNTM MATERIAL.
2.Well Construction Permit#: +3 ft 5 R 12 la1 Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL
3.Well Use(check well use): 17.SCREEN
Water Supply Well:. FROM TO DIAMETER.. SLOT SIZE .THICKNESS MATERIAL.
OAgricultuml OMunicipaUPublic 5 fe 20 ft4 2 i"` .010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft' in.
❑lndustriai/Commercial ❑Residential Water Supply(shared) 18.GROUT
.FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri tion . p l" 3 rt 'Grout Tremie
Non-Water Supply Well:
Monitoring . ❑Recovery
3 4 fLBentonte Pour
Injection Well: fit• fL
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM - TO- - MATERIAL - EMPLACEMENT METHOD.
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 20 ft. #2 Sand Pour
❑Aquifer Test OStormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
.20.DRILLING LOG attach additional sheets Wnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,karften,soWrwk tyM gMn ft etc.
❑G.eothemtal eating/Cooling Return) ❑Other(ex lain under#21 Remarks 0 .t. 3 R. Brown Clayey Silt
9/6/20 MW-34 3 fL 8 fL Gray Sandy Silty Clay
4.Date Well(s)Completed: Wen ID# g ft- 10.5 ft- Gray Sandy Clayey Silt
5a.Well Location: 10.5 ft- 20 tt. Gray Silty Sand
Colonial Pipeline
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Rd
R. ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102 - REV2
County Parcel Identification No.(PIN) Iwk
Sb.Latitude and Lollgitude in degrees/minutes/seconds or decimal degrees: 22.cersficatioD: f-;','FORMATInN PRnMSSING UNIT
(if well field,one laVlong is sufficient) ��c'�%-P`
611273.038 N 1461934.811 W a7 ► g aJ
Signature of nified Well Contractor Date
6.Is(are)the wen(s): OPer manent or ❑Temporary By signing this form,1 hereby certify that the wrll(s)was(we're)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surfaee:.20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100) construction to the following:
10.89 Division of Water.Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) 1Lg
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Auger 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this formI within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013