GW1-2021-07673_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1
1.Well Contractor Information:
Thomas Whitehead 1R.WATER ZONES
FROM TO DESCRIFfION
Well Contractor Name B• R•
2907-A ,t fL
NC Well Contractor Certification Number 15.OUTER CASING Por multi cased we0s OR LINER If a licable
FROM - "TO DWNETER THICKNESS MATERIAL -
SWE Inc ft. fL In.
Company Name 16.INNER CASING OR TUBING' eotherms]closed-loo
WM0301152FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 IL 25 fL 2 to SCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Infection,etc.)
fit. f1.' In.
3.Well Use(check well use): 17.SCREEN,
Water Supply Well:. -- - .. - FROM . TO "- DIAMETER'" SLOT SITE " .THICKNESS MATERIAL "
❑Agricultural OMimicipal/Public 25 fL 40 fL 2 In, .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft In.
❑lndustrial/Commercial ❑Residential Water Supply(shams) I&GROUT
.. - FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
OIrrigation . p ft. 6 M Grout Tremie
Non-Water Supply Well: g R. 23 fL Bentonite Pour
OMonitoring []Recovery
Injection Well: ft.
❑Aquifer Recharge OGroundwater Remediation 19:SAND/GRAVEL PACK ii licsble
- FROM. � TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 23 ft. .40 tL #2'Sand Pour
❑Aquifer Test ❑Stormwater Drainage
fit. fir.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attaeh additions]sheets ifnmess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hnrdn solUroelcmm,own etc.
❑Geothermal eating/Cooling Retum ❑Other(explain under#21 Remarks) 0 fL. 30 ft. Red Brown.Clayey to,Sandy Silt
9 30 fL 40 rt. Gray SiltySand
4.Date Well(s)Completed: "/6/20 Well ID#MW-28 y . "
ft. B.
5a.Well Location: fL
Colonial Pipeline R
Facility/Owner Name Facility ID#(if applicable) fit. fL
V16 2021
13926 Huntersville-Concord Rd n ,L
Physical Address;City,and Zip 21.REMARKS
Mecklenburg 01921212 TION PRTRRSING Q
County Parcelldernification No.(PIN)
56.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
610218.934 N 1461369.873 W Id 6 L,;)J
Signature of Miificd Well Contractor Date
6.Is(are)the well(s): 2Perrnanent or ❑Temporary By signing this form,I hereby certify that thewell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 01C:0200 Well Construction Standards and that
7.Is this a repair to an existing well: ❑Yes or E3No copy ofthis 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
g.Number of wells constructed: 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: 40 qt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q@200''and 1@100) construction to the following:
29.37 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:.. (tt.) g
Ifwater level is above casing use"+^ 1611 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 forth 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 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