GW1-2021-07676_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 7A RZONES
FRROMOM TO DFSCIt<p'rtON
Well Contractor Name ft. ft.
2907-A ft.
NC Well Contractor Certification 15.OUTER CASING for multi-cased wells OR.LINER a`Bcable
FROM .TO DIAMETER THICKNESS .. MATERIAL
S8tME lnc ft. a: In
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
WM0301152
2.Well Construction Permit#: +3 fc .28 IL 2 to1 Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc:)
ft- ft. to
3.Well Use(check well use): 77.SCREEN
Water Supply Well:• - .. FROM. 'TO DIAMETER SLOT SIYE .THICKNESS MATERIAL..
DAgricultural 0Municipal/Public 28 fL 57 2 in. .010 SCh 40 PVC
..
OGeothernal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. In.
❑lndushial/Commercial ❑Residential Water Supply(shared) I&GROUT -
- FROM - TO .MATERIAL EMPLACEMENT METHOD&AMOUNT :-
13hrigation 0 tt. 3 ft Grout Tremie.
Non-Water Supply Well: 3 ft 25 IL Bentonite Pour
Monitoring. ❑Recovery .
Injection Well: . ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK a`"licable
DAquifer Storage and Recovery ❑SalinityBarrie[ FROM. TO MATERIAL. EMPLACEMEN7METHOD
❑Aquifer Test OStorrnwaterDrainage 25 57 & #2Sand Pour
tt. R
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets►f.necessa
❑(3eothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness;soil/rock n ete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 11- 3 ft. Red Blown Silty CWy
9/4/20 Mw-25 3 e 10 Red Brown Clayey Silt
4.Date Well(s)Completed: Well II)# 10 IL 57 IL Brown to Gray Silty Sand
5a.Well Location: . ft. g
Colonial Pipeline
Facility/Owner Name Facility IM(if applicable)
14511 Huntersville-Concord Rd
tI. R
Physical Address City,and Zip 21.REMARKS
Mecklenburg 01940102 REV 2
County Parcclldentification No.(PIN) DWR zu'tv
il
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
610724.207 N 1462220.540 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): mPer'manent or ❑Temporary By signing this form,I hereby certify that the well(s)cons(we're)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
7.IS this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the well owner.
Ifthis 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
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiplelnjection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:.57 (ft.) 24a. For An.Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lid8erent(example-3@200•and 2@1001 construction to the following:
43.52 Division of Water.Resources,Information.Processin Unit,
10.Static water level below top of casing:. (ft.) g
Ifwater 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 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 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