GW1-2021-07693_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 1RWATERZONES
FROM TO - - DESCRIPTION
Well Contractor Name R. ft.
2907-A % ft.
f
NC Well Contractor Certification Number 15.OUTER CASING iLor mult4cased webs OR.LINER 'a Rcable
FROM TO- DIAMETER THICKNESS MATERIAL
SWE Inc
Company Name 16.INNER CASING OR TUBING' eothermal dosed-loop)
WM0301152 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 ft.' 19 n• 2 In. SCh 40 PVC
List all applicable well permits(.e,County,State,Variance,Injection,etc:)
ft. ft;
3.Well Use(check well use): 17.SCREEN
Water Supply Well• FROM I TO I DIAMETER' SLOT SITE I.THICKNM I MATERIAL
❑Agricultural ❑Municipal/Public 19 fb 34 ft 2 In. .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f+ In.
❑Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
FROM TO -MATERIAL - EMPLACEMENT METHOD&AMOUNT
Oftrigation 0 ft 15 f4 Grout Tremie
Non-Water Supply Well: 15 % 17 R Bentonite Pour
Monitoring ❑Recovery
Injection Well ft ft
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a licable
FROM. TO MATERIAL. EMPLACEMENT METHOD .
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 ft- 34 tt #2 Sand Pour
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control
20-DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRH`nON color,horde soilfrock tym oWn size,eta
❑Geothermal(Heating/Cooling Return) ❑O_ ther(ex lain under#2i Remarks 0 ft 23.5 & Brown Sandy Play
8/25/20 MW-2 23:5 fl. 34 ft. Light Gray Silty.Sand
4.Date Wel(s)Completed: Well ID#
5a.Well Location: ft. ft.
Colonial Pipeline ft. ft.
Facility/Owner Name Facility 1D#(if applicable) %14511 Huntersville-Concord Rd % NUV 2
2021
Physical Addnss;City,and Zip 21.REMARKS
-Mecklenburg 01940102 REVOR8 ,,'JN
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one iat/long is sufficient)
610823.419 N 1461424.282 W
Signature of Certified Well Contractor Date./
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certff that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the wall owner.
Ifthis is a repair,fill out known well'construction information and explain the nature of the
repair under#11 remarks section or on the back of thisform. 23.SKe,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 necessary.
For multiple injection or lion-water supply wells ONLY with the satire construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
34.0 24a. For All Wells: Submit this form within 30 da of coro letion of well
9.Total well depth below land surface: (ft) Ys P
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
29.57 Division of Water.Resources,Information Processing Unit,
10.Static water level below top of casingd (ft)
Ifwater level is above caOng 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(gpro) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: we11 construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natrual Resources—Division of Water Resources Revised August 2013