GW1-2021-07679_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For internal Use ONLY: f
This form can be used for single or multiple wells
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1.Well Contractor Information:
Thomas Whitehead 1R.W^TERNE�
FROM TO _ ��DESCRIPTION Well
Contractor Nam ft. ft. j
2907-A
n. IL
�
NC Well Contractor Certification.Number 15.OUTER CASING for multi-cased weps�OR:LINER a licable '
FROM .TO DIAMETER .THICKNESS .. MATERMLL
SWE Inc in
Company Name 16.INNER CASING OR TUBINGtgeothermal dosed-loop)
WR03001 1.9. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4-3 ft. 15 fL 2 In' Soh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft.
3.Well Use(check well use):
17.SCREEN
Water SaPply Well:. - - - -. -FROM . TO - DIAMETER- SLOT SITE THICKNESS MATERIAL -
[]Agricultural OMunicipal/Public 15 fL 45 ft- 2 IM 010 $oh 40 PVC
OGeothennal(Heating/Cooling Supply) OResidential Water Supply(single) R ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT :.
FROM L TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation . 0 ft 6 tr. Grout Treinle
Non-Water Supply Well: g n• 13 fL Beritonife Pour
OMonitoring BRecovery
Injection Well: .
[]Aquifer Recharge ❑Groundwater.Remediation 19:SAND/GRAVEL PACK.flf a licable
. - FROM. TO. MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Saliniy Barrier 13 fi 45 ft- . #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control
4-
.20.'DRILLING LOG attach additionalsheets If necessa
❑Geothermal(Closed Loop) ❑Tracer FROM - - ..TO . DESCRIPTION color,hardness,-soNrock...tyM gndn dze;etc. -
❑Geothemral(Heating/Cooling Return) ❑Ether(explain under#21 Remarks),1 0 ft 35 f4 Gray Silt and Clay
9/2 1/20 MW-23R 35 fL 45 f` Grayish Brown Silty Sand
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: .
ft. fL
Colonial Pipeline ,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
13900 HUntersville-Concord Rd
ft. . ft. . V.
s7021
Physical Address,City,and Zip 21.REMARKS
.Mecklenburg 019212.04 Revision 2 DwR
County Parcel'Identification No.(PIN) INFORMATION PRO TR3ING UNI1
5b.Latitude and Longitude In degrees/minutes/seconds or decimal.degrees: 22.Certification.
(if well field,one Iat4ong is sufficient)
610088.879 N 1461555.526 W - 1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that
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 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: construction details. You may also attach,additional pages ifnecessary.
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: 45 (ft.) 24a. For All Wells: :Submit this form within 30 days of completion of well
For multiple wells list all depths jdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: N/A (ft.) Division of Water.Resources,Inforination.Processing Unit,
If water 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 form1within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013