GW1-2021-07685_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
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1.Well Contractor Information: f
Thomas Whitehead 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
29 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)'OR LINER if a Ocabie
FROM TO - DIAMETER -T�CKNFSS MATERIAL
SWE Inc It in;
Company Name 16.INNER CASING OR TUBING" eothermal closed-loop)
.
WM0301152 FROM To DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: +3 116 tc 12 Io Sch 40 1 PVC
List all applicable well permits(i.e.Coun)i,State,Variance,Injection,etc:)
tt. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well:• FROM TO DIAMETER SLOT SITE .THICKNESS MATERIAL
OAgricultural ❑Municipal/Public 10 ft 25 ft 2 I° 010 SCh 40 PVC
OGeothennal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT .
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft. 5 fp Grout Tremie
Non-Water Supply Well: 5 ft. 8 Bentonite Pour
OMonitoring. ORecovery
Injection Well: % . Yt
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if
MATERIALie
EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 ft- 25 ft #2 Sand Pour
OAquifer Test OStormwater Drainage IL
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DFSCRIMON cobr'hardn soWrock r2Ve,grain d2r,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 2 ft Topsoil Organics
8/3 1/20 MW-1 0 2 ft. 4.5 ft Red Brown Sandy Clay
4.Date Well(s)Completed: wellID# 4.5 It- 20 fL Red Brown to.Gray Clayey Silt
5a.Well Location: . 20 ft. 25 ft PWR
Colonial Pipeline ft. ft
Facility/Owner Name Facility to#(if applicable) ft. ft.14511 Huntersville-Concord Rd ft. ,z -
Physical Address;city,and zip
21.REMARKS
Mecklenburg 019401.02 REv
County parcel Identification No.(PIN) _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: V 6 202
(ifwell field,one IatAong is sufficient)
610518.259 N 1461415.944 W ® R � I i
si true of Certified Well contractor INFORMATION PRO SING UNIT
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(we're)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that
7.Is this a repair to an existing well: []Yes or 0N0 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
9.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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 2 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: N/"20' (ft.) Division of Water Resources,Information.Processing Unit,
lfwater 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
uger 24a above,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 formf;within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August Ml3