GW1-2021-07713_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 TU I DESCRIPTTON
Well Contractor Name rL &
2907 A IL ft
NC Well Contractor Certification Number IS OUTER CANG for mold-cased ELb a OR LINER it cable
FROM To DIAMSI k7HR THICKNESS MATERIAL
SWE Inc It, I
Company Name 16.INNER CASING OR TUBING eotbcrmal Nosed-too
FROM TO DIAMETER THICKNESS MATERTAL
2.Well Construction Permit#: t3 R• 33 2 2 in. SCh 40 PVC
LLY1 all applicable welt permits(Le.County,State,Variance,infection,etc.) ti
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMEM ISLOT SITE HI TCKNFM I MATERIAL
❑Agricultural ❑bhmicipaVPublic 33 ft. 48 2 l"' .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f fL in.
01ndustrial/Commercial ❑Residential Water Supply(shared) M GROUT
FRUM I TO MATERIAL EMPLACFd1tENT METHOD&AMOUNT
❑hri ation 0 fL 3 & Grout Tremie
Non-Water Supply Well:
©Monitoring ❑Recovery
3 ft. 31 ft- Bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater RemediatioJRM-b
19.SAND/GRAVEL PACK a table
❑Aquifer Storage and Recovery ❑Balmily Baa FROM TO MATERIAL EMPL4CEMFM MEMOD
ier 31 n• 48 h #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage R. R
❑Experimental Technology ❑Subsidence Control
20.DRILLING.LOG attach additional--beets If .netesss
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESMP110N cabr.hardnesasdurock(. rain size,eft-)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 0 R' 9 ft Brown Silty Clay
9/3/20 MW-20 9 IL 13 Red Brown Play
a.Date Well(s)Completed: Wen w# 13 R. 20 % Gray SItt Sand
Sa.Well Location: 20 fL 48 n. Gray QMylS� 1 ..
Colonial Pipeline R. fL
Facility/Ownor Name Facility ID#(ifapplicablc)
14511 Huntersville-Concord Rd � ft. t
Physical Address,City,and Zip 2L REMARKS
Mecklenburg 01940102
County Parcel Identification No.(PIN) NOV 16
5b.Latitude and Longitude in degrees/minubealseconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
610895.751 N 1462288.912
Sirnature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cm ify that the mell(s)war(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Felt Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO ropy nfthis record has been provided to the well owner.
Ifift is a repair,flit out knmm well construction information and explain the nature nf[he
repair under N21 remarks section or an the buck of this foram. 23.Site diagram or additional well detalls:
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 infection or non-water supply wells ONLY with the same cvnstmcdn.%you can
SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface: 48 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple we1h list all depths if diiffereat(exampt (P0 2Q100� construction to the following:
10.Static water level below top of casing 4. 2 0'an (ft_) Division of Water Resources,Information Processing Unit,
If water level is above casrnguse•+ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter. 8 (ill.) 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:
(Lc.auger,rotary,cable,direct puab,tic.) Division of Water 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 fomu within 30 days of completion of
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 Nortb Carolina Departiocca of Environment and Netwal Resources—Division of Water Raamoes Revised August 2013