GW1-2021-07680_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:
14.WATER ZONES
Thomas Whitehead FROM TO DESCRIPTION
Well Contractor Name ft. ft
2907-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING_ for multl•eased sells OR.LUYER f a 'ticable
FROM .TO DIAMETER .THICKNESS .. "MAT
ft. ERW. .
S&M.E.Inc fL In.
Company Name 16.1NNER.CASING OR TUBING ikeothermal closed-loop)
FROM TO DIAMETER TIIICKNF.SS MATERIAL
WR0300119
2.Well Construction Permit#: - +3 fL 19 fL 2 In. SCh 40 PVC
List all applicable well permits(t e.County,State,Variance,Infection,etc)
fL fL ht
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM" TO DIAMETER SLOTSITE THICKNESS MATERIAL"
[]Agricultural ❑MunicipaVPublic 19 ft 34 ft' 2 in. .010 Sch 40 PVC
ElGeotherrnal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' ft. In. "
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
. FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT :
01ni non . 0 ft- 3 Grout Treniie
Non-Water Supply Well: 3 rt. 17 n Bentonite Pour
OMonitoring " aRecovery
fL
Injection Well:
OAquifer Recharge OGroundwater Remediation 19:SAND/GRAVEL PACK" i liable
FROM, TO MATERIAL. EMPLACEMENT METHOD -
[]Aquifer Storage and Recovery ❑Salinity Barrier 17 fi. 34 ft #2 Sand POUT
❑Aquifer Test ❑Stormwater Drainage
ft. IL
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets Ifneeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCPJMON color,hardnen,'soil/rock rype,gnaln size,eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Rematics 0 tt• 6 ft Brown Silty Clay
9/3/20 MW-22R 6 ft 1.4 fL Red Brown Clayey Silt
4.Date Well(s)Completed: Well[DO 14 tt• 34 ft. Brown Silty Sand
5a.Well Location: ft ft - n
Colonial Pipeline R,
Facility/Owner Name Facility M.#(if applicable)
ft. ft
14511 Huntersville-Concord Rd fL ft
Physical Address,City,and zip
Mecklenburg 01940102 21.REMAwcs 2
County parcel Identification No.(FIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Y2,Certification:
(if well field,one lat/long is sufficient)
610918.335 N 1462111.418 W
Signature of Certified Well Contractor Date
&Is(are)the well(s): mPermaaent or ❑Temporary si rn this form,/ ca1 that the wells was we're constructed in accordance
By .g�'g this I hereby Iy (l.. ( )
with 1 SA NCAC 01C.0100 or 13A NCAC 02C.0200 Well Constmcdem 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.
Ifthis is.a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the batik 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:"34. (ft.) 24a. For All Wells: ,Submit this form within 30 days of completion of well
For multiple wells list all depths#different(example-3@200'and 2@100) construction to the following:
34.88 Division of Water Resources,Information Unit;
10.Static water level below top of casing: (ft.) g
Ifwaterlevel is above casing,use"+" 1617 Matz 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,cattle 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
13e: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