GW1-2021-07684_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 la.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R. fL
2907-A ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased weds OR.LIlVER If"a ftable
FROM .TO" DIAMETER TRICKNESS ".. "MATERIAL
SWE Inc ft. ft: In. .
Company Name
16.INNER CASING OR T 21NG eothermal closed-loo
WM0301152 FROM To DIAMETER TFIIC,CNESS MATERIAL
2.Well Construction Permit#: 0 20 In' SCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc:)
k. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well:. .. - FROM. 'TO .. DIAMETER SLOT SITE -THICKNESS MATERIAL..
(]Agricultural OMunicipal/Public 20 ft- 40 rt 2 in 010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R• in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO - .MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation . 0 fL ft.
17 . Grout Tremie..
Non-Water Supply Well: 17 R 18 ft- Bentonite Pour.
aMonitoring . ORmovery
k. fG
Injection Well:
.
OAquifer Recharge CGroundwater Remediation 19:SAND/GRAVEL PACK applicable)
"
FROM. To. MATERIAL. EMPLACEMENTMETHOD. .
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 ft. 40 fL #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft..
❑Experimental Technology ❑Subsidence Control
20-DRILLiNG LOG attach additional sheets Ifnecessa '
❑Geothemtal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardn soWrock etc
❑G.eothermal(Heating/Cooling Return) ❑Other(explain under#2i Remarks 0 ft- 3 ft. Dark Brown Clay
8/27/20 MW-12 3 fL 38 !L Light Brown Clay
4.Date Well(s)Completed: Well ID# fL [L
5a.Well Location: ft. it.
Colonial Pipeline L
FaciliWOwner Name Facility 011(if applicable) NOV
14511 0
Huntersville-Concord Rd ft` V
% ft.
Physical Address,City,aad Zip 21.REMARKS" DWR Mecklenburg 01940102 MATION PROCESSING UNIT
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: D� �
(if well field,one lat/long is sufficient) O
35.41455 _ N -80.8.0797 W '
Signature of Certified Well Contractor Date
6.Is(are)the wen(s): mPermanent 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
7.Is this a repair to an existing well: ❑Yes or EiNo copy of this record has been provided do 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 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: 1 construction details. You may also attach.additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same consfrucNan,you can
submit oneform. SUBMITTAL INSTUCTIONS
40.94 24a. For Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface:. (ft) ys mP
For multiple wells list all depths if different(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: N/"Q' UP Division of Water Resources,Information Processing Unit;
if water level is above casing,use"+^ 1611 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
24a above,"also submit a copy of this form within 30 days of completion of well
12.Well construction method: " 'u g e r 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 27699-1636
24c.For Water Supply&InjectioniWells:
13a.Yield(gpm) Method of test: t
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county heaIhth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013