GW1-2021-07670_Well Construction - GW1_20211116

I
WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead F4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. fL
2907-A R. IL
NC Well Contractor Certification Number 15.OUTER CASING Jfoj multi�ased wells OR LINER f a Noble
FROM TO DIAMETER THICKNESS .. MATERIAL
S&ME Inc Iti
Company Name 16.INNER.CASING OR TUBING' eothermal dosed-loop)
WM0301152FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 10 ft- 2 iO' Sch 40 PVC
List all applicable well permits 0.e.County,State,Variance,Infection,etc.) %ft. ft. In
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO - DIAMETER`, SLOT SITE THICKNESS -MATERIAL..
bAgricultural OMunicipal/Public 10 It. 25 rt.- 2 .010 SCh 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. R In
❑Mdustrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
. FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri tion 0- fL 6 1t.. Grout Tremie
Non-Water Supply Well:
©Monitoring ORecovery
6 % 8 fL Bentonite Pour
Injection Well: . M f
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery []Salinity Barrier 8 ft. 25 ft. #2 Sand Pour
❑Aquifer Test OStormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets Umecessa
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hsrdn soil/rock n stir,etc.
❑Geothermal(Heating/Cooling oolin Return 00ther(explain tinder#21 Remarks 0 ft 8 ft. Brown Clayey Silt
9/6/20 MW-33 8 fL 14 fL Gray Sandy Clay
4.Date Well(s)Completed: Well ID# .
14 rL 15 «. Gray Brown Silty Sand
5a.Well Location: . 15 R- 25 M Gray Sandy.Silt
Colonial Pipeline fL &
Facility/Owner Name Facility lEW(if applicable)
1 fL
4511 Huntersville'Concord Rd ft. ft.
Physical Address,City,and zip 21.REMARKS
Mecklenburg 01940102 ;REV-2 INUV I tj2021
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �, L':tv`v
(if well field,one lat/long is sufficient)
22.�•• L1.<ec� li91:ORMATION PR()('.FSSING UNIT
611254.113 N 1461864.564 W j i/gk
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCACI 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You tray use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same conshucdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@200'and 2@100) construction to the following:
13.2 Division of Water Resources,Information, Unit,
10.Static water level below top of casing:.. (ft.) Processing
Ifwater 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
13s.Yield(gpm) Method of test 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I 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