GW1-2021-07704_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 1R WATER ZONES t
FROM 7U DFSCRICIlON
Well Contractor Nerve ft n
2907-A ft•
NC Well Contactor Certification Number15.OUTER CASING for multi-cased wells)OR LllVER if 'li a kable)
FROM TO DIAMMOt TiRCK.NECS MATERIAL.
S&ME Inc ft. In.
Company Name 16.INNER CASING OR TUBING eotbermal elesed-loa
FROM .TO I DIAMETRR TMCKNM I MATIpUAL
2.Well Construction Permit#: +3 ft• 10 ft 2 1D I Sch 40 PVC
List all applicable well permits(t.e.Caunly,State,Variance,InJection,NO n. n. m
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAM"M SLOT SM KNFBS MC MATERIAL
❑Agriculttual ❑MunicipaL/Public 10 n, 25 2 I°' .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft rm
[Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FOM I TO MATERIAL F.MPLACI<MENT METHOD&AMOUNT
Chrigation 0 rt. g ft. Grout Tremie
Non-Water Supply Well:
6 ft. 8 ft' Benton tte Pour
SMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a eable
FROM TO MATERIAL EMPL.ACEMENTMMOD
❑Aquifer Storage and Recovery OSalinityBarrier 8 FL 25 n• #2Send Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG roach additional slimb If necessary)
❑Geothermal(Closed Loop) ❑Tracer mom I To DINCRIMON cobr,hardness sait/reek qpt.grole tune eft.)
❑Geothermal(Heating/Cooling Rehmm) ❑Other(explain under#21 Remarks) 0 ft. 8 R. Brown Clayey Silt
9/6/20 MW-32 8 R 10 it. Gray Sandy Clay
4.Date Well(s)Completed: arm ID# 10 ft- 13 R Gray Silty Sand
5a.Well Location: 13 R. 25 n, Gray Brown Silty Sand
Colonial Pipeline ft. ft•
Facility/Owner Name Facility ID#(ifopplicabic) ft• fL I ; ; �,- i
14511 Huntersville-Concord Rd
Physical Address,City,and Zip 2L REMARKS _ a
Mecklenburg 01940102 Re-V;S
County Parcel identification No.(PIN) !
5b.Latitude and Longitude ID degmes/minutes/seconds or decimal degrees: 22.Certif ation:
(r611207 899e )N 1461763.847 W �— _ Ia 1�1�.
Stguature of Certified Well Contractor Date
6.Is(are)the well(,): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)consawled in accordance
with 1 SA NCAC 02C.0100 or 15A 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 well owner.
Ifibis is a repair,fill out known well construction information and eiplain the nature oflhe
repair under#11 remob 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same constrwcdom you can
submit une furm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 2 (ft.) 24a. jrgr All Wells: Submit this form within 30 days of completion of well
For multiple urlls list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 6.1 9 (ft) Division of Water Resources,Information Processing Unit,
Ifxnrer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
8 24b.For Injection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: Cam)
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,cablq direct push,etc.)
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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.
Forst G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013