GW1-2021-07690_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:Whitehead
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Thomas Y Y I Iite1 lead 14.WATER ZONES
FROM - TO-. -- ..DESCRIPTION ..
Well Contractor Name ft. it
2907-A R.
NC Well Contractor Certification Number 15.OUTER CASING 4or multi-eased wells OR LiMR f a cable
FROM .TO DIAMETER IR 'ESS MATERIAL -
SWE Inc R. ft. is
Company Name 16.INNER CASING OR TUBING'(geothermal dosed400
WM0301152 FROM FSS TO DIAMETER TFIICKN MATERIAL
2.Well Construction Permit#: +3 Rr 9 (t. 2 In Sch 40 PVC
List all applicable well permits 0.e.County,State,F'ariance.Injection,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER SLOT SITE THICKNESS MATERIAL
OAgricultural OMunicipal/Public 9 fL 39 ft 2 .010 1 Sch 40 PVC
OGcothermal(Heating/Cooling Supply) OResidential Water Supply(single) fl ft. in
18 GROUT.
❑htdustrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL F7HPLACEMEhT METHOD A AMOUNT
OIrrigation 0 ft' 5 r4 Grout Treinie
Non-Water Supply Well: 5 ft 7 Bentonite Pour
EMonitoring ❑Recovery
Injection Well: R ft
❑Aquifer Recharge 06roundwater Remediation 19:SAND/GRAVEL PACK applicable)
FROM- TO MATERIAL - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier � ft. 39 rt #2 Sand Pour
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets If aeassa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIPTWN color,hodnen,sollfrock n etc.
❑Geothermal(Heating/Coofrn Return) ❑Other(explain under#21 Remarks)
0 n- 22.5 ft- Brown Sandy Clay
8/28/20 MW-5 22:5 fL 39 ft. Brown to Gray Silty Sand
4.Date Well(s)Completed: Well ID# fL
5a.Well Location: ft. n,
Colonial Pipeline ft ft.
FaciliWowner Name Facility II)#(if applicable) ft. ft.
r P
14511 Huntersville-Concord Rd fL ,t.
Physical Address;City,and Zip 21.REMARKS
Mecklenburg 01940102 REv2
County Parcel Identification No.(PIM UWR b,.L t iJN
5.b.Latitude and Longitude in degrees/minutestseconds or decimal degrees: 22.Certin ti m:
(if well field,one latAong is sufficient)
610997.941 N 1461596.988 W AAA
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)tins(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under#11 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: 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdlfferent(example-3Qa 200'and 2@I00) construction to the following:
27.04 Division of Water Resources Information Processing Unit,
10.Static water below top of casing:. (ft) � g
lfwater level is above casing use"+" 1617 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
Augr 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 �- 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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