GW1-2021-07708_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Usc ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.WATER ZONES E
FROM 7U I DFSC'RIPT7ON
Well Contractor Name It. ft.
2907-A ,t. ft.
NC Well Contractor Certification Number "L OUTER CASING for multhcased welt) If■ Ilceb e
FROM TO DIAMLTER T9rClCN s MATERIAL
S&ME Inc It. I 1- 1 1
Company Name, 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DiAMET61t I TA[CKNESS I MATERIAL
2.Well Construction Permit#: +3 ft 28 R• 2 In. Soh 40 PVC
List all applicable well permits(i.e.County,State,Variance,iryecdon,etc.) ft. 2
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SIATSM7E 7MCKNFSS MATERIAL
❑Agricultural ❑MnnicpaUpublic 28 ft' 57 tL 2 1O .010 Soh 40 PVC
CGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R m
ClndustrisUCommercial ❑Residcritial Water Supply(Shared) 19.GROUT
FROM TO MATERIAL. EMPLACERENTMMOD&AMOUNT
❑Ini ation 0 ft. 3 & Grout Tremie
Non-Water Supply Well:
(EMenitoring ❑Recovery 3 25 Bentonfte Pour
Injection Well: ft' M
CAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 25 II. 57 ft. 92 Sand Pour
❑Aquifer Test ❑Stormwater Drainage &
GFxperimental Technology ❑Subsidence Control
W.DRILLING LOG attach additional sheets necee
❑Geothennd(Closed Lump) ❑Tracer rFROMTO DESCRIPTION(color harder soWrock t. rain s6v.die)
❑Geothermal(Healmg/Cooling Retum ❑Other( lain under#21 Remarks) 3 Red Brown Silty Clay
9�4�20 MW-25 10 ft• Red Brown Clayey Silt
4.Date Wells)Compieted: We11 ID# 57 R• Brown to Gray Silty Sand
Sa.Well Location: ft.
Colonial Pipeline ,L ft.
Facility/OwncrNamc Facility M#(ifapplicable) N, ft. ^! I'
14511 Huntersville-Concord Rd
a m
Physical Address,City,and Zip 21.REARKS
Mecklenburg 01940102 Mne
County Parcel Identification No.(IT9
5b.Latitude and Longitude in degr+eeslsulnutes/seconds or decimal degrees:
22.Certification:
(if well field,one latllong is sufficient)
610724.207 N 1462220.540 w L� 6
SiJrdturc of Certified Well Contractor Date
6.is(are)the well(s): [aPernment or ❑Temporary By signing this jnrm,I hereby certify Thar the well(s)was(wem)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cammiction Standards and that a
7.Is this a repair to an existing well: ❑Yes or LINO copy ofthis record hms been provided to the well owne►.
If this is a repair,fill our known well construction informatina and explain the aan"of the
repair under#21 remarks 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 sauce construction,you can
submit oneforvn. SUBMITTAL IINSTUCTIONS
9.Total well depth below land surface; 7 (fL) 24a. For AI( Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3t^ja 200'and 2@100) construction to the fallowing:
10.Static water level below top of casing. 43.52 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servieetenter,Raleigh,NC 276991617
11.Borehole diameter: 8 24b.For Infection Wells ONLY: In addition to sending the form to the address in
(Tn.)
Auger 24aabove, also submit a copy of this form within 30 days of completion of well
12.Wellconstruction method: construction to the following:
(Lc.auger,rotary,cabio,diroct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a Yield(gpm) Method of test: �•For Water Supph"&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount well construction to the county 1heahh department of the county where
constructed.
Form G W-1 North Carolina Depaxriment of Environment and Natural Resources—Division of Water Resources Revised August 2013