GW1-2021-07724_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This from can be used for single or multiple wells
1.Well Contractor information:
Thomas Whitehead RwATERZONEs
FROM 7U I DESCRIP'IlON
Web Contractor Name ft. ti.
2907-A E.
NC Well Contractor Certification Number 15.OUTER CASING r!FML ..welts OE LINER i[a llcable
FROM TO DGMEt'ER Tfl1CKN&SF MATERIAL
SWE Inc ft IL
Company Name 16.INNER CASING OR TUBING thermal closed-too
FROM TO DIAMETER I TRICKNM MATERIAL
2.Well Construction Permit#: +3 ft. 9 fe 2 in Sch 40 PVC
List all applicable well permits f.e.County,Stale,Variance,injection,e1c.) !Z ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT Sri I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 9 ft. 39 fL 2 In. .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FAOM TO MATFdttAL FINPI.ACFd1tFd7T METHU➢&AMOUNT
❑hri atiwt 0 ft• 5 ft. Grout ; Trernie
Non-Water Supply Well:
oMonitoring ❑Recovery 5 ft. 7 Ii' Bentonite Pour
Injection Well: ft. &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a liable
FROM TO afA7FA1Ai. EMMALCEMEPr MErHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 7 It. 39 ft. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRUXING LOG attach additional ibxb ff necessa
❑Geothemtal(Closed LAW) ❑'racer MOM I TO D %M[PTiOx corm Mcdoess.ewutoek typt.grain sirs.etc
❑Geothermal(Heating/Cooling Return) ❑Other(-plain under#21 Rema&s) 0 & 22.5 % Brown Sandy Clay
8/28120 MW-5 22.5 ft- 39 ft• Brown to Gray Silty Sand
4.Date Well(s)Completed: Wen ID# ft. ft.
So.Well Location:
Colonial Pipeline ft. '�` 1�_1'
Facility/Owner Name Facility W#(if applicable) ft. ft.
14511 Huntersville-Concord Rd NOV 16 ?02
Physical Addles,City,and Zip 21ARKS
Mecklenburg .REM
01940102 tie vi <'Jet.)
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well lief$one IaUlong is snffiritmt)
610997.941 N 1461596.988 W 1011661
S' ture of Certifiod Well Contractor Date
6.Is(are)the well(s): 2Permaneat or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to,the well owner.
If this is a repai fill aut known well construction information and explain the nature of the
repair tinder#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',attaoh additional pages ifnecessary,
For multiple injection or non-water supply writs ONLY with the same constmedan,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ��'O (fL) 24a. For All Wells: Subm it this farm within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 27.04 (B) Division of Water Resources,Information Promsing Unit,
if water level is above suing use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: 8 (In) 24b.For Iniectlon 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
It Well construction method construction to the following:
(i.e.auger,rotary,cable,direct push,cm)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
13a.Yield(rpm) Method of test: Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resourcm—Division of Wetar Resouroes Revised August 2013