GW1-2021-07674_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Thomas Whitehead FROM
ERZoriES
ROM TO ON
Well Contractor Name R. ft.
2907-A ft.
NC Well Contractor Certification Number 15.OUTER CASING for multltased wells OR LINER f a llcable
FROM -TO DIAMETER .THICKNESS -I MATERIAL
SWE Inc ft. ft. In.
Company Name 16.INNER CASING OR TUBING eothermal elosed-loo
FROM TO DIAMETER _I THICKNESS MATERIAL
2.Well Construction Permit#: WM0301152 +3 IL 27 ft. 2 is Sch 40 PVC
List all applicable well permits(i.e.County State,Variance,Injection,etc.)
fL fL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DUMETER i SLOT SUE THICKNESS MATERIAL
OAgricultutal ❑Municipa]/Public 27 IL 42 fL 2 In. .010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) t ft. in.
01idustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT . .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
131rrigation 0 & 6 fL Grout Tremie
Non-Water Supply Well:
laMonitoring ORecovery
6 fL 25 fL Bentonite Pour
Injection Well: flt ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM TO - MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier 25 tt 42 IL J #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control
20..DRILL7NG LOG attach additional sheets itnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock n eta .
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks 0 11 ft. Red Brown Clayey Silt
9/5f20 MW-27 11 fL 14 fL Gray Brown Sandy Silty Clay
4.Date Well(s)Completed: well ID# 14 IL 42 ft. Gray Sandy Silt
5a.Well Location: ft. ft.
Colonial Pipeline 9L
Pacitity/Owner Name Facility ID#(if applicable) & ft.
14511 Huntersville-Concord Rd
fL ft.
NQV1
Physical Address;City,and Zip 21.REMARKS
Mecklenburg 019401.02 REV z
County Parcel Identification No.(PIN) INFORMATION PROCESSING 1 INIT
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latnong is sufficient)
610986.312 N 1462085.698 W a tL a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certify thai the-11(s)rns(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the hell owner.
If this is a repair,fill out known well conshuelion information and explain the nature of the
repair under#11 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
S.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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS-
9.Total well depth below land surface:42 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenr(example-3Q200'and 1@I001 construction to the following:
33.2/7 Division of Water Resources,Information Processing Unit,
10.Static water below top of casing:.. (ft.) B t+
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: to 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
13a Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form lwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county healih department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Rcsourucs-Division of Water Resources Revised August 2013