GW1-2021-07671_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: k
Thomas Whitehead 14.WATER ZONES
FROM TO '' DESCRIPTION
Well Contractor Name ft. fL
2907-A ft. `.
NC Well Contractor Certification Number 15.OUTER CASING_ for mult4easdd cod Is OR LINER f a 8cable
FROM .TO DIAMETER - THICKNESS .. MATERIAL
SWE Inc fL ft: is
Company Name 16.INNER CASING OR TUBING taeotherml dosed400
WM0301152 FROM TO DIAMETER THICKNESS MATERIAL .
2.Well Construction Permit#: +3 fL 10 R 2 Im Sch 40 PVC
List all applicable x+ell permits(e.County,State,Variance,Injection,etc.)
ft ft.
3.Well Use(check well use): 17.SCREEN "
Water Supply Well:. FROM TO DIAMETER SLOT SITE .THICKNESS MATERIAL .
❑Agricultural OMunicipal/Public 10 fL 25 fL 2 hL .010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) R ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT . .
. FROM. TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri tion . 0 ft. 6 Grout Tremie
Non-Water Supply Well: g ft. 8 Bentonite Pour
OMonitoring DRecovery
Injection Well:
❑Aquifer.Recharge DGroundwater Rentediation 19:SAND/GRAVEL PACK- a livable
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 tt. 25 & #2 Sand Pour
❑Aquifer Test .,OStormwater Drainage M:. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets N necessary)
❑Geothermal(Closed Loop) []Tracer FROM ' TO DESCRIPTION color Yards so0/rock n shr,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft., 8 fL Brown Clayey Silt
9I6/20 MW-32 8 ft. 10 fL Gray Sandy Clay
4.Date Well(s)Completed: Well II)# 10 fL 13 fL Gray Silty Sand
52.Well Location: 13 ft- 25 ft. .: Gray Brown Silty.Sand
Colonial Pipeline ft. IL
Facility/(Tuner Name Facility ID#(if applicable) ft. R.
14511 Huntersville Concord Rd tL ft: =
Physical Address;City,and zip 21.REMARKS
Mecklenburg 01940102 REV U NO
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Nr'ORMATION PROCESSING UNi'
(if well field,one lat/long is sufficient)
611207.899 N 1461763.847 W c C� t
Signature of Certified Well Contractor Date
C Is(are)the well(s): G31'ermanent or ❑Temporary By signing this form,I hereby,certify that the well(s)mus(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that
7.Is this H repair to an existing well: ❑Yes or EiNo copy of this record has been provided to the well owner.
Ifthis is,a repair,fill out.known imll'construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You.ray 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 surface: 25 (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 t@200'and 2@1001 construction to the following:
10.Static water level belo w top of casing: 16.19 (ft.) Division of Water Resources,Information Processing Unit,
.
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:.8 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in.
Auger 24a above, also submit a copy of this forth 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: 16M Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one Copy of this form l 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