GW1-2021-07734_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 FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. IL
2907-A ft• fL
NC Well Contractor Certification Number 15:OUTER CASING for multi�ased wells OR.LINER r a Ocable
FROM .TO" DIAMETER THICKNESS .. MATERIAL .
SWE Inc k. ft.. In.
Compaq Name W IVI 0301152 3o�NNER CASING OR TUBINNMGE(geothermal closed-loo
TER - . THICKNESS MATERIAL
2.Well Construction Permit#: + fL fL 2 la Soh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
k. k: In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE .THICKNESS MATERIAL
❑Agricultural OMunicipaUPublic 50 ft 65 ft 2 In .010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. f. in.
❑lndustrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT . .
- FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT :
❑Irri Lion 0 ft' 3 M Grout Tremie
Non-Water Supply Well: 3 k. 48 fL Bentonite Pour
OMonitoring []Recovery
Injection Well: fL %
OAquife.r Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a likable
. . .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft- 65 rL #2 Sand Pour
❑Aquifer Test OStormwater Drainage
ft. %
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG itttaeb additional sheets it neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eobr,hardness,eolUroelc n dze.ere
[]Geothermal(Heating/Cooling Return ❑other(ez lain under#2i Remarks) 0 M 65 ft. Red Brown.to"Gray Clayey Silt
9I9/20 MW-41 ft. ft.
Date Well(s)Completed: Well ID# .
ft. k.
5a.Well Location:, k. ft.Pipeline ,
Facility/Owner Name Facility ID#(if applicable) ft. k 6 �Z
14511 Huntersville-Concord Rd k. ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient)
610493.441 N 1462185..803 W 11 s
Signature Ceriified Well Contractor Da
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NC.tC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1JNo copy of this record has been provided to the well owner.
lfthis is a repair,fill out known well"construction information and explain the nature of the
repair under#21 remarks section or on the hock 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLYnith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jd8erent(example-3Q200'and 2@100) construction to the following:
10.3tatic water level below top of casing: (ft.)53.40 Division of Water Resources,Information.Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county her lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013