GW1-2021-07709_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or maple wells
1.Well Contractor Information:
Thomas Whitehead 14.
FROM ER ZONES
ROM TO I DE.4CRIPTtON
Well Contactor Name f1 ft
2907-A 1t• &
NC Well Contractor Ceatificatioo Number 15.OUTER CASING r tnnitl erred wepa OR--- If I Hcame)
FROM To DUMETER' Trr1C!'N�[S MATERIAL
S&ME Inc It•
Company Namo 16.INNER CASING OR TUBING' thermal ctosed-toa
FROM TO DLCHMR I THICKNESS MATERIAL
2.Well Construction Permit#: +3 & 39 ft- 2 i° SGh 40 PVC
Livi all applicable well permiiv(Le.County,Stale,Variance,Iryection,etc.) M ft•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DtAMrrER SLOT SM I IMCKNEAS MATERIAL
❑Agricultural ❑Munieipai/Public 39 1L 54 fL 2 1& .010 1 SCh 40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 1t- ft
❑Industrial/Comtormial ❑Residential Water Supply(shared) IL GROUT
FRUM TO MATERIAL EMPLACEMENT METBUD&AMOUNT
01ni tion 0 % 3 L Grout Tremie
Non-Water Supply Well:
3 % 37 n Bentonite Pour
faMonitoring ❑Recovery
Injection Well: ft R
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK applicable)
FROM . TO MATFdtIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑SalinilY Bunrie► 37 n 54 ti #2 Sand Pour
❑Aquifer Test ❑Stormwater Dminage tL
❑Experimental Technology ❑Subsidence Control
20.DRELMG LOG iattach add!661W shmts accessa
❑Geothermal(Closed Loop) ❑Tracer FROST I TO OUNCRIP110N ooler hardaerr,WVrea t)pe.train"err.
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) 0 f6 9 & Red Brown Silty Clay
9/4/20 MW-24 9 ft- 20 ft. Red Brown Clayey Silt
a.Date Well(s)Completed: wen ID# 20 % 25 ft. Brown Silty Sand
58.Well Location: 25 R- 34 ft. Brown Sandy Sift
Colonial Pipeline 34 ft 54 ft. Brown to Gray Silty Sand
Facility/OwncrNamc Facility M#(ifapplicable) ft ft• ! , t _ j I
14511 Huntersville-Concord Rd n
NOV ! 6
Physical Address,City,and Zip 2L Rri MtaRKR
Mecklenburg 01940102 pev 5i0h
County Parcel Identification No.(per
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latMng is sufficient)
610605.100 N 1462116.596 W
Signehrc of Ccrdficd c I Contractor Datc
6.1s(are)the well(s): OPermsinent or ❑Temporary ity signing this form,I hereby certify that the wells)was(were)constructed In accordance
with 15A NCAC 02C.0100 or I5A MCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Wes or ElNo copy of This record has been provided to the well owner.
If this is a repair,fill out knowsn well construction Information and explain the nature of the
repair under#21 re narkv 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 same construe ion,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface. 54 (ft) 249. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdpereni(example-3W- 00'and 2QI00) construction to the following:
10.Static water level below top of casing: 46.69 (L) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
(i8 24b.For Infection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: ti4)
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,mn.) Division of Water Resou
rces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
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; wall construction to the county 1health department of the county where
constructed.
Form G W-1 North Carolina Dt pmt wnt of Environment and Natural Resources—Division of Water Resmares Revised August 2013