GW1-2021-07683_Well Construction - GW1_20211116

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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 ZON>
FROM TO - DESCRIPTION Well Contractor Name ft. ft
2907-A ft. ft
NC We11Contractor Certification Number 15.OUTER CASING for multi cased wells OR.LINER a"'Ocable
FROM TO DIAMETER TinCKNESS .. MATERW. .
SWE Inc ft. rt in
Company Name FROM .CASING
- DIAMETERhermalclosed-loo -
WM0301152 12 TICKNESS MATERIAL
2.Well Construction Permit#: +3 INNER_fL 241NG O�TUBING �O is SCh 40 1pvC
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.)
R. ft, In.
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: - FROM. 'TO - DIAMETER ...SLOT SUE THICKNESS MATERIAL..
[]AgriculturalOMunicipal/Public 24 ft- 39 ra 2 �. .010 Sch 40 PVC
.OGeothermal(14cating/Cooling Supply) OResidential Water Supply(single)
ft. ft: In. .
idustriaUConunercial ❑Residenpal Water Supply(shared) 18.GROUT
❑It : .
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation p ft- 3 ft. Grout Tremie
Non-Water Supply Well:
lamonitoring. ORecovery .
3 n- 21 fL Bentonite Pour
Injection Well: . R. fr
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM - TO MATERIAL. - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 21 ft 39 " ft #2 and I POUT
❑Aquifer Test OStormwater Drainage ;
❑Experimental Technology ❑Subsidence Control
20:.DRILLING LOG attach additional sheets H necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color'hardn solUrock type,Vale efe
❑Geothermal eatin Cooli I ng Return ❑Other(explain under#21 Remarks 0 ft. 5 ft. Red Brown Silty Clay
a.Date Well(s)Completed: 9/2/20 Well ID#MW-1 5 5 ft- 39 � Red Brown Clayey Silt
ft. ft.
5a..Well Location: ft. ft.Colonial Pipeline
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Rd fteft ROcEss►N
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102 Rom,2
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or dechnal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
610450.293 N 1461470.456 W
Signature ofrcrtified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that'a
7.is this a repair to an existing well: ❑Yes or Mo copy of this record has been provided to the well owner.
If this 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: 39 (ft) 24a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100) construction to the following:
34.79 Division of Water Resources,Inforrtiation Processing Unit,
10.3tatic water level below top of casing: (ft.) n8
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 subunit 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 Man Service Center,Raleigh,NC 276994636
13a:Yield(gpro) 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