GW1-2021-07678_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:
Thomas Whitehead 14.
FRwATERZONES
FROM TO DESCRIPTION
Well Contractor Name h %
2907-A fL
NC Well Contractor Certification Number 15.OUTER CASING Lfor multl cased wells 0R LINER If a ticable
FROM TO DIAMETER THICKNESS .. MATERIAL - -
S&ME Inc ft. e. in.
Company Name 16.INNER CASING OR TUBING eo
W M 0301152 thermal d ICK
MATER ►L
FROM TO DLIMETER �� THICKNESS� � � L
2.Well Construction Permit#: +3 � 39 ft- 2 Ia Sch 40 PVC
List all applicable well permits(.e.County,State,Variance,Injection,etc.)
R. " fL In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: - - FROM - TO DIAMETER SLOT SITE .THICKNESS MATERIAL.
OAgricultural OMunicipal/Public 39 ft, 54 ft.- 2 in. .010 SCh 40 PVC
OGeotherrnal(Heating/Cooling Supply) OResidential Water Supply(single) R• fL In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
."FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
0hrigation 0 fL 3 IL Grout Tremie
Non-Water Supply Well:
3 fL 37 fL Bentonite Pour
O ❑RecovMonitoring . cry .
Injection Well ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Ilcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD37 ft-
[]Aquifer Test OStormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control
t.
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardy sailtrock tyM Vida etc.
❑Geothermal(Heating/Cooling Return ❑Other(e lain under#21 Remarks) 0 ft 9 ft. Red Brown.Silty Clay
9/4/20 Mw-Zee s ft 20 ft. Red Brown Clayey Silt
4.Date Well(s)Completed: Well ID#
20 rL 25 't• Brown Silty Sand
5a.Well Location: 25 it- 34 it. Brown'Sandy Silt
Colonial PIPellne 34 ft. 54 fL Brown to Gray Silly Sand
Facility/Owner Name Facility ID#(if applicable) iL ft.14511 Huntersville-Concord Rd ft.
fL
Physical Address,city,and zip 21.REMARKS .s
Mecklenburg 01940102 REV IV
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
610605.100 N 1462116..596 w �, MR S kl=i
Il PR
Signature ofCcnificd Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 01C.0100 or 15.4 NCAC'02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo 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 of this form. 23.Site diagram or additional well details:
You may use the back of this page I 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 54 Vt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
46.69 Division of Water Resources,Information.Processi0 Unit,
10.Static water level below top of casing: (ft.) g
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (In.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Auger 24aabove, 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!within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county"where
constructed. G
s
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013