GW1-2021-07726_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.WATERZONES
FROM TO I DESCR1PliUN
Well Contractor Name tL n.
2907-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for"multi can vclls OR LINER if cable
FROM Tn DIAMEI'FR THICKNE.tiS MATERIAL
S&ME Inc fL ft
Company Name 16.INNER CASING OR TUBING' thermal elosed-loo
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: t3 fL 17 n. 2 t Sch 40 1 PVC
List all applicable well permits(l.e.County,Stale,Variance,injection,ec.)
n. I n. �.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SiZE TIIiCIt1V&4g MATERIAL
❑Agricultural ❑Municipal/Public 17 n• 30.0 fL 2 In. .010 1 Sch 40 PVC
❑Geothermal(Iieating/Cooling Supply) ❑Residential Water Supply(single) fL ft. In.
❑IndustrialtlCommercial ❑Residential Water Supply(shared) I&GROUT
FROM TU MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It. 13 R. Grout Tremie
Non-Water Supply Well:
❑Recovery
13 ft. 15 fLBentotilte Pour
©Monitoring
Injection Well: n n
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK a liable
FROM TU MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 15 ft 30 fL #2:Sand Pour
❑Aquifer Test ❑StotmwaterDrainage ft. n.
❑Experimental Technology ❑Subsidence Control
20.DRII.LING LOG attaeh additional alueis R ncceraa
❑Geothermal(Closed Loop) ❑Traces FROM I TO DESCRtrrtan color,tuna sot0roek type.Zrain size,ete
❑Geothermal(Heating/Coolink Return) ❑Other( lain under#21 RemaTks) 0 n 13 ft. Brown Sandy Clay
8/25/20 MW_3 13 fL 130 fi. Light Gray Silty Sand
4.Date Well(s)Completed: We11 ID# fL &
Sa.Well Location: 2 fL
Colonial Pipeline n & NO d
Facility/OwncrName Facility IDtt(if applicable) n. fL
14511 Huntersville-Concord Rd
Physical Address,City,and Zip 2L REMARKS -
Mecklenburg 01940102 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/®nutes/seconds or decimal degrees: 22.Cc lion: t'
(if well[lard one lat/bug is sufficient)N W —���� 1
610971 .458 1461854.757 o�i a 1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wel(F)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copy of this record has been provided to the well owner.
if this is a repair,fill out kwnm well construction information and explain the nature of the Site diagram or additional well details:
repair ender N21 remarks section or on the back of this form. 23.
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 iron-wafer supply wells ONLY with the saute constwdion,yvu can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30'O _(ft) 24a. For All Wells: submit this farm within 30 days of completion of well
For multiple wells list all depths ifdii fereat(example-3@200'and 2Qa 1001 construction to the following:
10.Static water level below top of casing: 22 78 VL) Division of Water Resources,Information Processing Unit,
if woter level is above casing use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
8 24b.For Inieeaon Wells ONLY: In addition to sending the form to the address in
(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,ctc.)
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: 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county heahh department of the county where
13b.Disinfection type: Amount constructed
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resamces Revised August 2013