GW1-2021-07727_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor lnformation:
Thomas Whitehead 14.WATER ZONES
FROM TO DESCRIP'IiON
Well Contractor Name ft. ft.
2907-A R. %
NC Well Contractor Certification Number 15.OUTER CASING for mnitl-eased wells OR LINER if a Hcable
FROM TO A[AME1'IJi TRICKHI:SS MATERIAL
S&ME Inc tL n I to.
Company.Name 16.INNER CASING OR TUDING' eotbermal closed400
FROM TO DIAMETER I TirCKNESS I MATERIAL
2.Well Construction Permit#: +3 fL 19 2 m. Sch 40 PVC
List all applicable well permits fix.Counly,State,Variance,lyecti0q etc.)
n. n. ia.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRIC CKMq MATERIAL
❑Agricultural ❑Municipal/Pubhc 19 ft. 34 ft- 2 in. .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. ft. Im
❑Industrial/Commemial ❑Residential Water Supply(shared) 111.GROUT
FROM TO MATERLLL EMPLACEMENT METHOD&AMOUNT
011rixotien 0 ft. 15 ft' Grout Tremis
Non-Water Supply Well:
15
OMonitoring ❑Recovery ft' 17 ft' Bentoriite Pour
Injection Well:
❑Aquifer Recharge ❑Gloundwaten Remediation 19.SAND/GRAVEL PACK a liable
❑Aquifer Storageand Recovery ❑Salim Barrier FROM TO MATFAM&L EMPLACEMENT METHOD
tY 17 ft• 34 n. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. fL
OExpetimental Technology ❑Subsidence Control
20.DRILLIIVG LOG attach additional sleets If accessary)
❑Geothermal(Closed Loop) ❑']'racer rROM I TO DESC'RiP710N fcobr..hordntm sWmd.hpg.Itraln slue.etc.
❑Ge.Dthermal Heating/Cooling Retum) ❑hater(explain under#21 Remtaft) 0 It 122.0 ft. Data available from boring log SB-37
8/24/20 MW-1 22 fL 134 fL Dark Gray silty Sand
4.Date Well(s)Completed: Well ID# % ft.
5a.Well Location:
Colonial Pipeline ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. R n I/ 1
14511 Huntersville-Concord Rd fL fL
Physical Address,City,and Zip 2L REMARKS Jc'
Mecklenburg 01940102 vis;arr, . j
County Pwrcl Identification No.(PIId)
r,
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
W 22/�T itiDD: — ��Lmla1
(ifwell field,,o lat/Long is sufficient)
610872.421 1461603.523
N
Stgoanmc ofCcrtificd Well Contractor Date
6.is(are)the wlll(s): OPermaneut or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A MCAC 02C.0100 or 15A MrAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an exlsfing well: DYes or ONo copy of this record has been provided in(he well owner.
Ifthis is a repair,fill out known well construction hiformadan and explain the nature of the
repair tinder 921 remarks seedon 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
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-waier supply wells ONLY with the same constme i0A you can
submit unejotm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ��'0 (ft.) Us. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a0 dettihs if dif ferent(example-3(ds200'and 2@1 M construction to the following:
10.Static water level below top of casing: 28'20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 8 0m.) 24b.For Iniection Wells ONLY:] In addition to sending the form to the address in
24aabove, also submit a copy of form within 30 days of complexion of well
Auger
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-Mail Service Center,Raleigh,NC 27699-1636
24a For Water Supply&Iniceti a wells-
Also Yield(gpm) 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013