GW1-2021-07705_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
14.WATEA Thomas Whitehead '") I
IDE4CRIP1IUN
Well Contractor Name ft ft
2907-A ft,
NCWcIIComrectorCertificationNumber Is.OUTER CASING rmuld-cased:wells OR LINER i(a ticeble
FROM TO DIAMETER TflICKNFSS MATERIAL
SWE Inc ft. in,
Company Name 16.INNER CASING OR TUBING al desedaao
FROM TO DIAMETER I THICRQMMS I MATERIAL
2.Well Construction Permit#: t3 IL 20 fL 2 In. Sch 40 PVC
Livi all applicable well permits(<.a Caunty,Stale,Variance,Injection,etc.)
fl. ft. ln.
3.Well Use(check well use): 17.SCREEN
Water supply well: FROM TO DIAMETER I SLOT SIZE I "HCKNESS I MATERIAL
❑Agricultural ❑MlmieipaUPublic 20 ri- 35 ra 2 m. .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it ft i1p'
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL F.MPLA.CFdNENT METHOD&AMOUNT
Chrigatian 0 ft. 3 ft- Grout Tremie
Non-Water Supply Well:
EMonitoring ❑Recovery 3 rt 18 ft• Bentorilte Pour
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Balmily Battier FROM ft. TO MATF.RtAL EMPLACEMENT METHOD
18 35 & #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG laftat addifl sal sheets if neeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,eardans 9MVMCL bpt,tn1dsh*,etr.)
❑Geothermal(Heating/Cooling Rehm) ❑Other(explain under#71 Remarks) ft. ft.
9/7/20 MW-30 ft. ft.
4.Date Well(s)Completed: Well D)# f4 ft.
Sa.Well Location: % ft.
Colonial Pipeline ft, ft
l
Facility/Owner Name Facility tD#(if applicable) ft. &
14511 Huntersville-Concord Rd ft. ft. NOV 16
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102
County Parcel Identification No.M
5b.Latitude and Longitude in degmesl®nutestseconds or decimal degeea: 22.Zertffltion:
(if well field,one lat/long is sufficient)
610799.782 N 1461554.298 W 16 i G 421
Miriftm of Certified Well Contractor Date
6.is(are)the well(s): BPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)%us(were)constructed in accordance
with ISA NCAC 02C.0700 or ISA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Met copy of this record has been provided to the well owner.
If this&a repair,fill out iinnwtt well construction information and explain the nature of the
repair reader#21 r emanb section or an 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
&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
srtbmit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 5 (fL) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@a 100'and 2@1001 construction to the following:
10.Static water level below top of using: 30 59 00 Division of Water Resources,Information Processing Unit;
If water fevel is above casing,use"+^ 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (ln.) 24b.For Iniection Wells ONLY: In addition to sending the form m the address in
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,cable.direct push,etc.
Division of Water Resources,Underground L(jection 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013