GW1-2021-07687_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: i
Thomas Whitehead 14.
FRROMOM FROM ER F TO DESCRIPTION
Well Contractor Name ft. ft.
2907-A fL tL
NC Well Contractor Certification Number 15.OUTER CASING for maM1 used wells)OR.LINER f a ticable
FROM- .TO DIAMETER -THICKNESS .. MATERIAL
SWE Inc ft. ft: In.
Company Name 16.INNER CASING OR TUBING' eothermal closed-loop)
WM0301152 FROM TO DIAMETER I THICKNESS MATERML
2.Well Construction Permit#: +3 fL 20 2 : is SCh 40 PYc
List all applicable well permits(i.e.County,State,Variance,Infection,etc:)
fL ft In
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: FROM TO DIAMETER' " SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 20 ft 35 tL. 2 la 010 $Ch 40 PVC
DGeothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft
ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01trization p ft., 16 ft: Grout Tremie.:
Non-Water Supply well: 6 IL 18 ft Beritoni4e Pour
SMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a livable
- "FROM. - TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier $ tt 35 f4 #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG sttaeh addltlonal sheets ffneeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hsrdn soWrock etc
❑Geothermal eatirig/Coo6n Return ❑Other(explain under#21 Remarks) 0 fL 8.5 ft Orange Sandy Clay
8/30/20 MW-7 8.5 fL 16 Brown Clayey Sand
4.Date Well(s)Completed: Well ID# 16 fL 35 ft Gray ri SII Send
5a.Well Location: .
fL ft
Colonial Pipeline fL
Facility/Owner Name Facility W#(if applicable)
14511 Huntersville Concord Rd
IL ft. ' NOV 19 202i.
Physical Address,City,and Zip 21.REMARKS'
Mecklenburg 01940102 REV DWR&L, i 1N
County Parcel Identification No.(PW INFORMATION FROCES$
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
6109.83.987 N 1462042.726 W sy a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form.I hereby,terrify that the well(s)xus(were)constructed in accordance
with 15A NCAC 01C.0100 or ISA NCAC 01C:0200 Well Construction Standards and that
7.Is this a repair to an existing well: ❑Yes or allo 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#11 remarks section or on the bock 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 xdth the same construction,you can
submit oneform. SUBMITTAL INSTUCPIONS
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 if different(example-3@200'and 2@I00� construction t0 the following:
31 .77 Division of Water.Resources,information Processing Unit,
10.Static water level below top of casing:.. (ft)
If water level is above casing use"+" 1617 Marl 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.c.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
24c.For Water Supply&Injection Wells:
13s.Yield(gpm) Method of test:
Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. C
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013