GW1-2021-07682_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 1RwATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2907-A ft. 'L
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased OR LINER f a licable)
-FROM -TO DIAMETER 1 THICKNESS MATERIAL .-
SWE Inc ft. I ft In.
Company Name 16.INNER CASING OR TUBING`(geothermal dosed-loop)
WM0301152FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 ft. 30 fL 2 is Sch 40 1 PVC
List all applicable well permits(i.e.County,State,Variance,Infection,etc)
ft.
fL In•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: .. - FROM . TO DIAMETER SLOT SITE .THICKNESS MATERIAL..
❑Agricultural OMunicipal/Public 30 fL 45 fL 2 Ia' .010 SCh 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft to
0Ind0strial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 fL 3 & Grout Tremie
Non-Water Supply Well:
3 ft. 27 fLBentonite Pour
3Monitoring ❑Recovery
Injection Wen: ft. IU
❑Aquifer Recharge OGroundwater Remediation 19:SAND/GRAVEL PACK ■ licable
FROM. TO . MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
27 ft- 45 f4 #2 Sand Pour
❑Aquifer Test OStormwater Drainage
ft. fl.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attaeb additional sbeets 11-n6uss
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Color Garda soWrock n size ete
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarics 0 ft. 6 ft. Red Bfown:Sby.Clay
9/2/20 MW-18 6 ft. 15 f4 Red Brown Clayey Silt
4.Date Well(s)Completed: Well ID# 15 fL 45 ft. Gray Silty Sand
5a.Well Location:. . g, fL
Colonial Pipeline ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL NUV 02
14511 Huntersville-Concord Rd fL fL
Physical Address;City,and Zip REMAR 21. KSDWR
�.r•J
.Mecklenburg 01940102 1 PROCESSING Nil
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(61081one7.943G1�t)N 1462185.479 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0(00 or 15A NCAC102C.0200 Well Construction Standards and that a
7.is this a 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 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 if tiecessary.
For multiple injection or non-water supply wells ONLY with the same constrticdon,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 if different(example-3Q200'and 2@100) construction to the following:
39.10'8 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:.. (ft.) rag
Ifwater 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 Mill 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013