GW1-2021-07701_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 14.
PROM TU DESCRIPTION
Well Contractor Name It. ft
2907-A
NC Well Contractor Certification Number 14.OUTER CASING for multi-eased wells OR LINER If a cable
FRAM TO DtAMY-FER TFOCKN64S MATERIAL
S&ME Inc �- �•
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THTCRTIFBS MATERIAL
2.Well Construction Permit#: +3 rt. 15 ft. 2 Sch 40 PVC
List all applicable well permits ft.a County,State,Variance,Injection,etc.)
iL ft. to
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT S12E I nUCKNEsc I MERiAL
❑Agricultural ❑Munitap&Public 15 ft. 37 ft. 2 1a' ,010 Sch 40 PVC
❑Geothermal(lieating/Cooling Supply) ❑Residential Water Supply(single) ft' ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri tioD 0 fL 6 ft- Grout Tremie
Non-Water Supply Well:
RMonitoring ❑Recovery 6 ft, 13 ILBentoriite Pour
Injection Well: ft ft'
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier 13 fL 37 ft. #2 Send Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG attach additional sheets tf mcettu
❑Geothermal(Closed Loop) ❑Tracer FROM TO DI;SCRt "ON ctilm ardaen suWrock 13pe,grala siee,etz.
❑Geothermal(Hestia tooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft. Red Brown to Gray Clayey Silt
9/7/20 MW-35 1, ft. 37 iL Gray Sandy Silt
4.Date Well(s)Completed: WeII ID# ft. ft.
Sa.Well Location: ft. ft.
Colonial Pipeline
Facility/OwnerName Facility JD#(ifopplicabic) ft. ft.
14511 Huntersville-Concord Rd ft. Nev 1 �02
Physical Address,City,and Zip 2L RJUdARKS
Mecklenburg 01940102
County Parcel Identification No.(PIN) t .. ...
5b.Latitude and Longitude in degrees/minutes/swonds or decimal degrees: 22.Cc tion:
(if we0 field,one lat/long is sufficient)
611009.321 N 1461705.220
Signature of certified Well Contractor Date
6.IS(are)the well(s): OPermanent or ❑Temporary By signing this forest,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Randards and that a
7.Is this a repair to an eiisting well: EMS or E)No copy of this record has been provided to the well owner.
1f this Is a repair,Jill mat Amwm well construction lnformatian and explain the nature ofthe 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. agram
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 construcdon,you can
submit one form. SUBMTITAL INSTUCTIONS
9.Total well depth below land surface: 37 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(e Wle-3(dy200'and 2@1000 construction to the following:
26.78 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft')
Ifwrrter level is above coring,use"+ 1617 Mail Service Center Raleigh,NC 27699-1617
1I.Borehole diameter: 8 (in.) 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.e.auger,rotary,cable,direct push,cte.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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 lieelth department of the county where
constructed.
I
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of W ata�Resources Revised August 2013