GW1-2021-07700_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead F14.
FROM TER ZONES
ROM 70 DESCRIPTION
Well Contractor Name II. rL
2907-A fl. fL
NC Well Contractor Certification Number 1'.OUTER CTA Gfor mull-cased weh ORACIEQVRFS s a . 1enble
FROM O mAMEr6R MATFRIAL
S&ME Inc ff• Ift. in.
Company Now 16.INNER CASING OR TUBING(geothermal ctosed400
FROM TO DUMET'F.R TMCKNESS I MATFRW.
2.Well Construction Permit#: +3 fL 27 R 2 In. Sch 40 PVC
List all applicable well permits(ie.County,Stare,Variance,Injection,etc.) B. %
3.Well Use(check well use): 17 SCRE914
Water Supply Wen: FROM TO DiAMEfER SLOT SEE "UCKNL4s MATERIAL
❑Agricultural ❑Mtn icipaVPublic 27 IL 42 ft- 2 Iti.' .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Rcsidential Water Supply(single) R ft
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01tri ation 0 ft. 6 It. Grout Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
6 % 25 fL Bentoriite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.&4WGRAVEL PACK a licable
FROM TO MATERIAL EMPI.ACEMFM MMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rier R.
25 42 #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
0.DRt3.LIlVG LOG attach addldopal sbeete if uectasa
❑Geothermal(Closed Loop) ❑Tracer FROM ITO DLNMWT ION color luirdnes%solltmi.iyM gnin sles'tic.
❑Geotheffial{Hearin :Cooling Retina ❑Other( lain under#21 Remaacs 0 27 fL Red Brown to Gray Clayey to Sandy Silt
9/8/20 MW-36 27 fL 42 rt. Gray Silty Sand
4.Date Well(s)Completed: Well ID# R ft.
5a.Well Location: ft. ft.
Colonial Pipeline n. n 1",, ,� <<<
Facility/OwaerName Facility lD#(if applicable) ft R
14511 Huntersville-Concord Rd R Q ,
Physical Address,City,and zip 2L REMARKS
Mecklenburg 01940102 nevj �iov i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minates/seconds or decimal degrees: 21 Certification:
(if well field,one latilong is sufficiera)
610925.672 N 1461745.145 w
gnature of Certified Well Contractor Date
6.is(are)the wen(s): mPermanent or ❑Temporary By,signing this form,I hereby certify that the we/10 xns(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consauttion Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record hat been prrivided to the well owner.
If this is a repair,jdl out known well construction information and explain the nature ofthe
rrpair tender#21 remaga section or an the back of ddsform. 23.Site diagram or additional well detans:
You may use the back of this page to provide additional well site details or well
6 Number of wens constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same can.mucdaq you can
submit une farm SUBMITTAL INSTUCTTONS
9.Total well depth below land surface: 42 (fL) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all dey the if di fermi(example-3@200'and 2@1001 construction to the following_
10.Static water level below top of casing: 28.62 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above cassing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
8 24b.For Iniecdon Wells ONLY In addition to sea the form to the address in
11.Borehole diameter: (in.) �
Auger 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction metbod: construction to the following;
(i.e.auger,rotary,table,direct push,ctt.)
Division of Water Resource's,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injectil u Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health deportment of the county where
constructed.
Farm G W-1 North Carolina Deportment of Euvuoament and Natural Resourm—Division of W ate R.,,.s Revisod August 2013