GW1-2021-07694_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:
Thomas Whitehead FROM ERzorrEs
FROM TO DESCRH'TION
Well Contractor Name R. R.
2907`-A . it. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mult4cased wells OR.LUYER f a licoble
.FROM TO DIAMETER - THICKNESS .. I MATERIAL .
SWE Inc fL fL tu-
Company Name 16.INNER CASING OR TUBING tgeothermat closed-loo
WM0301152 FROM To DIAMETER TRICIQ�ESS MATERIAL
2.Well Construction Permit#: +3 ft. 19 n• 2 Ia Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL tt: In
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S12Z THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public 19 fL 34 fL 2 In. .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tL tL In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1&GROUT . .
FROM TO .MATERIAL - EMPLACEMENT METHOD&AMOUNT
❑hri tion 0 R• 15 fL Grout Tremie
Non-Water Supply Well: 15 f4 17 n Bentonite Pour
OMonitoring ❑Recovery
Injection Well ft. fL
❑Aquifer Recharge ❑Groundwater Remediaiion 19.SAND/GRAVEL PACK a tkoble
FROM. TO- MATERIAL - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 h34 ft #2 Sand Pouf
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets tf necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,'bardn soWrock type,pain shy,etc
❑Geothermal(Heating/CooGn Return) ❑Other(explain under#21 Remarks 0 h• 22.0 fL Data available from boring log SB-37
8/24/20 MW-1 22 ft� 34 ft. Dark Gray silty Sand
4.Date Well(s)Completed: Well ID#
Sa.Well Location: . R• fL
Colonial Pipeline ,� fL
Facility/Owner Name Facility ID#(if applicable) & &
14511 Huntersville Concord Rd ft ft.
Physical Address;City,and Zip 21.REMARKS -.,
Mecklenburg 01940102 .
County Parcel7dentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiri oD
(if well field,one 1atAong is sufficient
610872.421 N 1461603.523 W )
Signature of Certified Well Mtrictor Date f'w•
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby eerbfy that the xvell(s)was(were).constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC.02C:0200 Well Construction Standards and that
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the wet/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: 1 construction details. You may also attach additional pages if necessary:
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCPIONS
34.0 24a. For Ati Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface:. (ft.) ys P
For multiple wells list all depths ijdifferent(example-3@200'and 2@I00) construction to the following
10.Static water level below top of casing: .
28.20 Division of Water Resources,Information Processing Unit,
.. (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: iIn 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013