GW1-2021-07675_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 FROM O W^T. TO FROM DESCRH'TION
Well Contractor Name ft. fL
2907-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR.LINER f a "ticable
FROM TO DIAMETER 'THICKNESS - -MATERIAL
SWE Inc rt. rt: In.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
WR030011 g FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 R. 22 ft2 Ia SCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc:)
R. it in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM. TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 22 iL 37 it 2 1- .010 SCh 40 PVC
OGeothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. fL, in
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT' ,
FROM TO - .MATERAAI. EMPLACEMENT METHOD&AMOUNT
01rrigation . p rt. 3 ft- Grout Tremie
Non-Water Supply Well: 3 it. 20 fL Beritonite Pour
❑Monitoring_ BRecovery
Injection Well:
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK" a licable
. FROM. TO MATERIAL. - I EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier 20 ft 37 ft.' #2'Sand POur
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20:111RILLiNG LOG attach additional sheets If•necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,'hardness,soWmoh type,aWn tie "
❑Geothermal(Heating/Cooling Return ❑Other(ex lain under#21 Remarks 0 fL 13 ft. Red Brown.Sllty Clay "
9/4/20 MW-261R 13 R 20.. Red Brown Clayey Silt
4.Date Well(s)Completed: Well ID# .
20 R. 37 R. Gray Silty Sand
5a.Well Location: . ft. ft
Colonial Pipeline ,
Facility/Owner Name Facility iDll(if applicable) ft. ft.
14511 Huntersville-Concord Rd R. NnVLj
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 019401.02 Revis,
County Parcel'Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,onelatAong is sufficient)
610924.172 N 1462017.515 W
Signs ure of Certified Well Contractor Date
6.Is(are)the well(s): 12Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 1 SA NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No 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
8.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 surfacer 37 qt.) 24a.. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
33.25 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:.. (fit.) �
Ifwater level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 276994617
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
l2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pusk 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