GW1-2021-07725_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used far single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14 WATER7
FROM TO 72) I DFSCRIP'ITON
Well Contractor Name h• it j
2907-A
NC Well Contractor Certification Number 15.-OUTER CASING for mrellE-caseel webs OR LINER a ltesble
ft.FROM TO DIAMET'FJI THICKNESS MATERIAL
S&ME Inc ft.
Company Name I&INNER CASING OR TUBING dosedaoo
FROM TO DIAMETER I THICKNESS MATERIAL.
2.Well Construction Permit#: +3 fL 10 fL 2 in Sch 40 PVC
List all applicable well permits(;.e.County,State,Variance,lryeclion,etc.)
it. 1 ft. hL
3.Well Use(check well nse): 17.SCREEN
Water Supply Well: FROM To DTAM TKR SLOT SCM MnCKNns MATERIAL
❑Agricultural ❑MemicipaVPubflc 10 ft. 40 ft' 2 ln' .010 Sch 40 PVC
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ft ft'
❑ladustrial/Commercial ❑Residential Water Supply(shared) 1B GROUT
F80M TO MATERIAL EMPLACEMENT METHOD @ AMOUNT
OlrriLation 0 ft. 6 fL Grout Tremie
Non-Water Supply Well: R.
SMonitoring ❑Recovery 6 8 ft. Ben---- Pour
Injection Well: n' ft
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SAND/GRAYEL.PACK Of Applicable)
FROM To MATE
❑Aquifer Storage and Recovery ❑Salinity Bar 8 40 #2 ier ft. f. #2 EMPLACEMF Po atstHom
Sand Pour
❑Aquifer Test ❑Stotmwater Drainage & it.
❑Experimental Technology ❑Subsidence Control 20.DRELJ ING LOG I attach additional sheets if neoecsa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIMION cubr.hardmen,tMVrock t rem aiee.etcm)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadcs) 0 ft 14 ftBrown Sandy Clay
8/28/20 MW-4. 14 fL 40 fL. Gray Brown to Gray Sift Sand
4.Date Well(s)Completed: WeB 1D# ft. ft
5a.Well Location:
Colonial Pipeline & Noll
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Rd ,t
Physical Addm%,City,and Zip 21.REMARKS -•�r;l:'LT(1 r �,, 7+_
Mecklenburg 01940102 I �� �t,, ,
vi l �
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreWminutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) t,
610775.085 N 1461415.603 W ' ., .`, oaf« o
Signature of Catificd Wcll Contractor Date
6.Is(are)the well(s): OPermanemt or ❑Temporary By signing this form,I hereby cereify that the writ(s)was(wvre)constructed in accordance
with 1JA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Stanrhwh and that a
7.Is this a repair to an existlng well: ❑Yes or E)No copy of this record has been provided to the well owner
lfthis is a repair,fdl out knmw well conrnwfinn infnrmatinn 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
9.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water suppIy weth ONLY with the same conxlwedon,you can
»tbmtt one juror. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 40.0 (fL) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdijjerent(example-3(ja 200'and 2QQ I001 construction to the following:
10.Static water level below top of casing: 31 .32 ( ) Division of Water Resources,Informadon Processing Unit,
lfwate►level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (ln)
8 24b.For InIKdon Wells ONLY: In addition to sending the form to the address in
Auger 24aabove, also submit a copy af!this form within 30 days of completionof 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 Mall Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
13a Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health depatttnemt of the county where
constructed.
Form G W-1 North Carolina Departeacut of Environment and Natural Resources-Division of Water Ronwces Revised August 2013