GW1-2021-07710_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.WATER ZONES
FROM TO DESCRIPTION "
Well Contractor Name R R
2907-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased webs OR.LUVER f a Nable
FROM- TO- - DIAMETER .THICKNESS MA'r'Farer.
S&M.E.Inc n. e. In.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
WR0300119
2.Well Construction Permit#: In
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) +3 IL 4 SCh 40 PVC
RR 10 in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 10 ft- 50 ft- 4 "1 .010 SCh 40 PVC
❑Geother ial(Heating/Cooling Supply) ❑Residential Water Supply(single) R R' In.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.-GROUT . .
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigation . 0 k• 6 ft- Grout Tr6mie
Non-Water Supply Well: g ft. 8 R Beritonite Pour
oMonitoring . aRecovery -
Injection Well: ft: ft,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
- -
❑Aquifer Storage and Recovery ❑Salinity B FROM TO MATERIAL EMPLACEMENT METHODarrier 8 rt, 50 IL #2 Sand Pour
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Contra]
20:DRILLING LOG attach additional sheets B-neceasa
[]Geothermal(Closed Loop) []Tracer FROM TO DESCR[MON color'kardn soiltrock type,grain etc
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) 0 ft. 50 ft Red.Brown to Gray Sandy Silt
9/21/20 RW-32 ft.
4.Date Well(s)Completed: Well ID#
fL (L
5a.Well Location: g. ft.
Colonial Pipeline
1t. ,L
Facility/Owner Name Facility ID#(if applicable) ft. NOV 16 2021
14511 Huntersville- ft.
Concord Rd ft.
Physical Address,City,and Zip 21.REMARKS, bL%,i i N .
Mecklenburg 01940102 WeSItI MN PROCESSING UNIT
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wcll field,one lat/long is sufficient)
610887.01 N 1461973.617 E W
Signature of Certified Well Contractor Date
&Is(are)the well(s): laPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Information and explain the nature 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
8.Number of wells constructed: 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
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 -ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdoerent(erample3Q200'and 1Qa 100r) construction to the following:
e-
10.Static water level below top of casing: ' `/'20` (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 10 (in.) 24b.For Injection 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,etc.)
Division of Water Resources,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: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013