GW1-2021-07672_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can W used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft• IL
2907-A ft &
NC Well Contractor Certification Number 15.OUTER CASING Lfor multl-eased Reps OR.LUIIER f e llcable
FROM TO DWHETER THICKNESS I MATERIAL -
SWE Inc ft• it. in.
Company Name 16.INNER CASING OR TUBING' eothermal closed-loop)
WM0301152 FROM To DIAMETER TMCKNESS MATERIAL
2.Well Construction Permit#: +3 fL 20 fL 2 in. SCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Infection,etc.) ft.. ft. 1n
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNFSS MATERIAL
❑Agricultural ❑Municipal/Public 20 fL 35 fL 2 in .010 SCh 40 PVC
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fL is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT . .
FROM TO .MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑lni tion . 0 % 3 fL Grout Tremie
Non-Water Supply Well: 3 ft 18 fL Benton'ite Pour
iaMonito'ing,. ORecovery
Injection Well: k. ft.
[3A'quifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK- a Hcable
FROM - TO- - MATERIAL EMPLACEMENT MEMOD.
OAquifer Storage and Recovery ❑Salinity Barrier 18 fa 35 fL . #2Sand Pour
❑Aquifer Test OStormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach addidonsi sheets If-neconsa
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION wler'hardn soWroek tyM FWD SIZe,ete.
❑Geothermal(Heatin Coob I ng Return) ❑Other(explain under#21 Remarks) ft. ft
4.Date Well(s)Completed: 9I7/20 Well ID#MW-30 fL
ft. fL
5a.Well Location: . ft. ft.
Colonial pipeline ft RR
-
Facility/Owner Name Facility ID#(if applicable)ci f
14511 Huntersville-Concord Rd ft.
ft. fL
Physical Address;City,and Zip 21.REMARKS
Mecklenburg 01940102 R.EV 21NIFORmATioNP .'F
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
610799.782 N 1461554.298 W g _S
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9INo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@100) construction to the following:
30.59 Division of Water Resources Information Processing Unit,
10.Static water level below top of casing: (ft.) g
If water level is above casing use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Auger 24a above, 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
i
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 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