GW1-2021-07749_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for angle or mulliplo wens
1.Well Contractor Informatlont
R ZONES;-
Thomas.Whitehead FROM -1 TO FROM. To DwcunI r
Well Commactor Now R. P.
2907-A
OR LINER f a
NC Well laonoactor Certification Number Ig.'OUTF,R CASI G feu aiaNFafad wells
F1lOM. . -TO � DIAMETER MATERIAL
SWE Inc
Comps Name Ia.INNER CASING OR TUBING hermalelesed
FROM TO . DIAMETER - TInCKNL0.9 MATLRIA4
2.Well Construction Permit N: +3 n. 25 n. 2 In SCh 40 PVC
Ltsr anafflikeMe wriipermits(t.r.Cotmfy,stone,I arlomr,hvtvdon,etc.) n. I
3.Well Use(cheek well use): 17.SCREEN
Oat TO DIAMETER .SLOT a1ZL IICTCNus MAT[lUA
Water Supply Well: 25 n. 40 n 2 ter. .010 Sch 40 PVC
OAgticultaral OMunicipaVPublic to
OGeothermal(Heating/Cooling Supply) OResidentiai%Voter Supply(single)
n. n
Olnduslri&l Commercial OResidendal Water Supply(shared) le.GROUT
pp y ) FROM TO "MATERIAL ONFUCEMEC•T MLTNODiAMOUNT
Olrri Lion 0 n• 6. n. Grout Tremie
Non=Water supply Well: g n. 23 R Sentonfte Pour
ORecovery
BMonitaing
Injection\ven -
OAquifer Recharge OGroundwater Remediation t 1l.SAND/GRAVEt:PA • ko a+`
FROM TO _WATERIAL EMM ACEMENT MLfHOD'
OAquifcr Storage and Recovery OSalini0'Barrier Y3 R• 40 #2 Sand Pour
OAquifer Test OStorrrtwatcr Dminage f. n
OExperimental Technology OSubsidenee Control 20..DRILWNG I OG attaa sddlNanat abren If aeea+sa -
Doeothermal(Closed Loop) OTmcer fo t To DFSCR rnoN mw kare aNvr.aa ■see err.
OGeodmTr l(Hestin tin Return) pother(explain under#21 Remarks 0 It. 30: n Red.B.rown Clayey to Sandy Sift.
11�W-28 30 rt 40 � Gray Silty Sand
9/6/20
4.Date WeD(s)Completed: Well JI—
ID n, n.
Sa.Well Location: R. IL
Colonial Pipeline
FaciligtO%i=Narae Fscitity fL n.'
13926 Huntersville-Concord Rd ft. �.
Pbyacal M&css,City.sad Zip — �21. MARKS r
Mecklenburg 01921212 wasi a
fib' Parcel Identification No.(PIN)
Sb.Latitude and Longitude ID deBreeslmMoteslseeonds or decimal degrees: 22.Certification:
(if wen field.are 4t/bng is auRcienf)
610218.934 N 1461369.873
Siouturc of Ccnified well Contractor Date
6.Is(arc)the well(s): OPermaaent or OTemporary By sigalns this)arm.'I herby cerrw that the wv11(r)nw(hire)consnuew in accordance
with 13A NCAC o2C.6100 or 13A NCAC.01C.0300 Wen Conrourden Standards and rhos a
7.Is this a repair to an tabling wtD: OYes or ONO ropy of this record her been provided to the 1e11 owner.
IlrhLr is a repair,fill our brown wvIl construction information and explain the nature ofthe 29 Site diagram or additional well details:
repair under#21 rtniarks seedon or on the back of thirforre.
You may use two bask of ibis page to provide additional well site derails or well
lls constructed: construction details. You rosy also atuch additional pages if necesury.
8.Number of we
Fop muh/p/elg1tellonwnon•wuter supply nrllrONLY with the same eonrmtedon.loucan SUBMITTAL INSTUCTIONS
submuoneJorm.
fL 24s.For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: 40 ( ) construction to the following:
For multiple welts list all depths(/dderent(example•3 200'and 2®100)
10.Static water level be w lop of taslog: 29.37 (f.) Division of Water kesources,Information Proeesslag Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
1f hater level it above casing.ere"+" .
11.Borehole diameter,8 (in.) 24b.For lalle0on Welb ONLY: In addition to sending the form to the address in.
Q 24aabove,also Submit copy of this form within 30 days of completion of well
12 Well eocstructlon method: ' `uger construction to the following:
(i.e,suger,rotar)4 cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center;Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
24e.For Water uuDly&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of.this form within 30 days of completion of
well construction to the county health department of the county where
13b.Disinfection type: Amount: constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Wstcr Resources Revised AuVw 2013
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