GW1-2021-07686_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 F14.
ROM ROM WATER TO TO
F � DESCRIPTION
Well Contractor Name It. ft.
2907-A ft. %
NC We)]Contractor Certification Number 15.OUTER CASING for multi-eased wells OR.LUHER f a licable
FROM TO DIAMETER THICKNESS _ MATERIAL
SWE Inc ft.. ft. in.
16.INNER CASING OR TUBING eothermal
Company Name dosed-loop)
WM 0301152 FROM TD DUMETER TMCKNESS MATERUL
2.Well Constriction Permit#: +3 ft 19 2 Ia SCh 40 PVC
List all applicable well permits(r e.County,State,Variance,Injection,etc:)
R. fL iR
3.Well Use(check well use): 17.SCREEN
Water Supply Well: - - FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL..
❑Agricultural OMunicipal/Public 19 fL 34 fL 2 to. .010 SO 40 PVC
OGeothemtal(Heating/Cooling Supply) ❑Residential Water Supply(single) R R• in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
. FROM TO .MATERIAL- EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 h• 15 tt. Grout ! Tremie
Non-Water Supply Well: 15 ft 17 fLBeritonite Pour
SMonitoring. ORecovery .
Injection Well ft. R.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM - TO MATERIAL. EMPLACEMENT METHOD - -
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 fL 34 ft: #2 Sand Pour
❑Aquifer Test ❑StormwaterDrainage .% fL
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color'herdn' soilfrock tyM gmn
size,etc.
❑Geothermal(Heating/Cooling Return I Other(explain under#21 Remarits O n• 4 N• Brown Sandy CIBy
8/31/20 MW-9 4 & 29.5 fL Red Brown to Gray Clayey sand
4.Date Well(s)Completed: Well ID#
29.5 34 Brown Silty Sand
5a.Well Location: ry, ft.
Colonial Pipeline fL
Facility/Owner Name Facility ID#(if applicable) ft. fL 1
14511 HuntersVille-Concord Rd Ito
NOV
Physical Address,City,and Zip 21.REMARKS
Meckienburg 01940102 REV 2 RS;: „�N
County Parcel Identification No.(PIN) iblEOR MR �nJ P
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(6110766 024 sufficient)N 146160.6.198 W
Signature of Certified Well Comme or Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(we're)constructed in accordance
with 15A 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 E]No. 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 if riecessary.
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: 34 (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 2Q100) construction to the following:
28.80'2 Division of Water Resources,Information.Processin Unit,
10.Static water level below top of casing:.. (ft.) g
If water level is abovecasing.use"+" 1617 Marl 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,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: 24e.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