GW1-2021-07689_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead FROM
ERZANES -
ROM TO J DESCRIPTION
Well Contractor Name R. ft.
2907-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multttased wells O_ R LINER f a 'ticable
FROM .TO DIAMETER .THICKNESS .. MATERIAL .
SWE Inc R. I ft. in.
Company Name 16.INNER CASING OR TUBING'(geothermal closed-loop)
WM0301152FROM TO DIAMETER I THICKNESS. MATERIAL.
2.Well Construction Permit#: +3 ft . 10 I: 1,2 In- I Sch 40 1 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc:)
R. ftr IR
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: FROM. 'To DIAMETER SLOT SITE THICKNESS MATERIAL..
❑Agricultural ❑Municipal/Public 10 f0 40 ft. 2 in. .010 Sch L40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) R fL. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
. FROM TO - .MATERIAL EMPLACEMENT METHOD&AMOUNT
131tri tion 0 rt. 6 14 Grout Tremie
Non-Water Supply Well: g n• 8 Bentonite Pour
laMonitoring ❑Recovery
]injection Well: . ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if a licable
. .FROM TO- MATERIAL EMPIdCEMENT METHOD- -
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 ft. 40 % #2 Sand Pour
❑Aquifer Test OStormwater Drainage ft.
fL
❑Experimental Technology ❑Subsidence Control
.20.DRILLING LOG attach additional sheets ff mess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION cotor,'harda wWmk a eic.
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks 0 ft. 5.5 ft. Brown Silty Sarid
8/29/20 MW-6 5.5 tL 13 fL Gray Sandy Silt
4.Date Well(s)Completed: Well ID# 13 IL 22.5 IL Gray.Silty Band
5a.Well Location: . 22.5 R• 40 ft.
y '
Colonial Pipeline n, n. f r-,
Facility/Owner Name Facility ID#(if applicable) It.
14511 Huntersville-Concord Rd ft: fLNOV 2021
Physical Address;City,and zip 21.REMARKS JN
Mecklenburg 01940102 ocEsswuw
County Parcel Identification No.(PIN)
5.b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lavlong is sufficient)
610954.120 N 1461495.917 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC;01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or BNo 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 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:40 (ft.) 24a. For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@100') construction to the following:
27.04 Division of Water.Resources,Information Processing
Uoit;
10.Static water level below top of casing:.. (ft.) �
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 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form L 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