GW1-2021-07721_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 DESCRH'TION
Well Contractor Name ft. ft
2907-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multl-eased wells OR LINER f a '11cable
- 'FROM TO DIAMETER THICKNESS .. MATERIAL
SWE Inc ft. 1a
Company Name 16.INNER CASING OR TUBING' eothermal dosed-loop)
WMO3O115ZFROM TO DIAMETER THICKNESS. MATERIAL
2.Well Construction Permit#: +3 ft 11 ft 4 in. Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Infection,etc:)
ft. fL
in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO I DIAMETER I SLOT SITE 1.THICKNESS MATERIAL
bAgricultural OMunicipal/Public 11 fL 46 ft• 4 iD .010 1 Soh 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft it'_ In
L I
❑hidustrial/Cotnmercial ❑Residential Water Supply(shy) 18.GROUT
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Ofirigation 0 ft- 6 ft. Grout Treinie
Non-Water Supply Well: 6 % 8 fL Bentonite Pour
.taMonitoring ❑Recovery
Injection Well:
R. ft.
[]Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK a likable
FROM. - TO MATERIAL. - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier 8 ft-, 46 to #2 Sand Pour
[]Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eobr hardn wNrocic n etc.)-
❑Geothermal eating/Coolin Return ❑Other(ex lain under#21 Remarks 0 ft• 40 ft. Gray brown Sift
9/15/20 MW-48 40 11, 46 fL Gray silty sand
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. IL
Colonial Pipeline
Facility/Owner Name Facility ID#(if applicable) R. ft.
14511 Huntersville-Concord Rd ft. fL
Physical Address,City,and Zip
Mecklenburg 01940102 21.REMARK3 R« EsslNcuNl
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaU 22.Certification:
long is sufficient)
610606.396 N 1461638.047 E W 912"0
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E INo 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
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 construedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: ,Submit this fomt within 30 days of completion of well
For multiple wells list all depths iftifferent(example-3@200'and 2Q10q construction to the following:
10.Static water level below top of casing: N/A (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 Iniection 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,'Undergroued IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:
,. .
Also submit one copy of this form within 30 days of completion of
t t ti u well construction o he county health department of the county where
13b.Disinfection type: Amount: ;.
constructed.
Form GW-1 North Carolina Departimm of Environment and Natural Resources-Division of Water Resources Revised August 2013