GW1-2021-07681_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for.single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.WATER ZONES
FROM TO DFSCRIYTION
Well Contractor Name ft. ft.
2907-A ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt4cased wells OR LINER a '8eable . ' '
FROM TO DIAMETER THICKNESM .. MATERIAL
SWE Inc R. I fL in.
Company Name 16.INNER CARING OR TUBING'` eothetmal dosed-loo
WM0301152 FROM TO' DIAMETER 7$1CKNEMS. MATERIAL
It,Well Construction Permit#: . +3 33 rl 12 in. Sch 40 "
List all applicable well permits(Le.County,State,Variance,Infection,etc.) PVC
k. fL" in
3.Well Use(check well use): 17.SCREEN
Water Supply Well:. - - .. FROM. TO DIAMETER SLOT SI7Lr -THICKNESS MATERIAL..
❑Agricultural bmunicipal/Public 33 to 48 fL 2 1° .010 Sch 40 PVC
[]Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) R n. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
-FROM L TO - .MATERIAL- EMPLACEMENT METHOD&AMOUNT :[]Irrigation . 0 n• 3 k• Grout Trernie
Non-Water Supply Well: 3 R. 31 n Bentonite Pour,
IaMonitoring . ❑Recovery .
Injection"Well: ft. tt;
[]Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK PACKQf a liable
❑Aquifer Storage and Recovery []Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
31 ft- 148 ft #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. fL
20:DRILLING LOG attach sdditlonal sheets if•necess
❑Geothermal(Closed Loop) ❑Tracer FROM- - -TO .-DESCREMON(color,hardness,soi]V—k a etc.
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 0 tt• 9 tt Brown Silty Clay
4.Date Well(s)Completed: 9/3/20 Well ID#MW-20 9 R• 13. .fL Red:Brown Clayey Silt
13 a 20 a Gray.Silty Sand
Se.Well Location: 20 a 48 R Gra..Cl I Silt
Colonial Pipeline ,
Facility/Owner Name Facility iD#(if applicable) k, ft .. -
14511 Huntersville-Concord Rd
Physical Address,City,and zip 27.REMARKS
Mecklenburg 01940102 R `z,_i
allakl
County Parcel Identification No.(PIN) `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(6110�895 a751 eient)N 1462288.912 W
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:0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the well owner.
If this is a repair,fill out Anawn well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same construction;you can
submit one form. R SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft,) 24s For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:.42'25 (ft) Division of Water.Resources,Information.Processing Unit;
If water 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 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,"direst push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-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 constriction 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