GW1-2021-07698_Well Construction - GW1_20211116

I
I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4.
Thomas Whitehead F FROM Fdt7 TO ROM To DFscRtPTiox
Wall Ctmtmctot Name ft. ft.
2907-A
ft. >ti I �
15.OUTER CASING(For mnfi-cascd` db O1I R fa llbleNC Wall Contractor Cixt9cationNumber FRAM tiM FRIAI.
SWE Inc ft. & I to.
Company Name 16.INNER CASING OR TUBING eethermal dosed-loop)
FROM TO IDIAMETER TFUCKNESS MATERIAL
2.Well Construction Permit#: +3 ft- 20 ir. 2 hL Sch 40 PVC
Liw all applicable well permlis(Le.Crnmly,Statg Parlance,Injection,etc.)
ft. R. I bL
3.Well Use(check well use): 17.SCREEN
Water Supply Welh FROM I TO I DIAMETER SLOTSrlE TFDCKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic 20 ft- 35 ft 2 " 1 .010 1SCh 40 PVC
❑Geothermal(Heeting/Cooling Supply) ❑Residential Water Supply(single) ft' ft
Olndustrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT.
FROM TO MATERIAL EMPLACEMENT METHDD&AMOUNT
131ni ation 0 rt. 8 ft. Grout Tremie
Non-Water Supply Weil:
lamonitoring ❑Recovery
6 ft. 18 ILBentonite Pour
Injection Well: ft. ft.
[]Aquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK if 'cable
0A uifer Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL EMM.ACEMMT MEMoD
q g �' ty 18 it. 35 ft. #2 Sand Pour
❑Aquifer Test ❑Stomtwater Drainage
ft. ft.
OExpe imental Technology ❑Subsidence Control
20.DRILLING LOGS attach additional sheets ffneensaryl
OGeothelmal(Closed Loop) ❑Tracer ]'ROM I TO Dr.r_RIPTION color,hardness soil/rock 43pt.grain size.eh.)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 35 0. Red;Brown to Gray Clayey to Sandy Silt
9/8/20 MW-37 ft•
4.Date Well(s)Completed: Well ID# ft. it
Sa.Well Location:
Colonial Pipeline -
Facility/Owner Namc Facility m#(if applicable)
14511 Huntersville-Concord Rd fL
fl. ft. NOVI6
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102
County Pared Identification No.(PAT)
5b.Latitude and Longitude In degrees/minuteslseconds or decimal degrees: 22.Certilication:
(if well field,one lai/long is sufficient)
610847.989 N 1461775.311
of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary gy signing this form,J Aerehy cerlff,that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0/00 or 15A NCAC 02C.02M Well Construction Randar&and that a
7.Is this a repair to an eilsting well: ❑Yes or E)No copy of this record has been provided to the well owner.
Jf this&a repair,fill nut known well construction information and explain the nature of the
repair tinder#21 ra marla 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
S.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 unejorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form wit in 30 days of completion of well
For multiple wells lit(all depths if different(example-3Ca 200'and 2Q100) construction to the following:
10.Static water level below cop of casing:
26.90 Division of Water Resources,Information Processing Unit,
(fL)
Jf water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 276W1617
11.Borehole diameter. 8 (>a) 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.c.auger,rotary,cable.diced 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 form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form G W-1 Norh Carolina Department of Enviromn®t and Natural Resources-Division of Wsus Resomoes Revised August 2013