GW1-2021-07691_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 FRO WATER zorr>
FROM TO _ DESCRIPTION
Well Contractor Name IL IL
2907-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING_ for mold-cased wells OR LINER f a Ncmble
FROM TO_ DIAMETER THICKNESS MATERIAL
SWE Inc ft. fL In.
Company Name 16.INNER CASING OR TUBING eother &I dosed-loo
WM0301152 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 ft. 10 & 2 In. Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
ft. ft, in
3.Well Use(check well use): 17.SCREEN
Water Supply Well:• FROM - 'TO DIAMETER SLOTSI7E .THICKNESS MATERIAL"
OAgricultuml ❑Municipal/Nblic 10 It. 40 fL 2 In. 1 .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R ft. to
18.GROUT
❑hidustrial/Commercial ❑Residential Water Supply(Shared) FROM TO MATERIAL EMPLACEMENT METf10D&AMOUNT
Olrrigation " 0 f' 6 ft. Grout Trtsmie
Non-Water Supply Well: g ft 8 tt " Bentonite Pour
Monitoring" ❑Recovery
Injection Well: ft. f
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM, TO MATERIAL - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier' g ft. 40 ft; #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessa
[]Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION 4color,hardness,soit/mc c tyM grain dze,etc
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 ft• Brown"Sandy Clay
8/28/20 MW-4 14 ft. 40 & Gray Brown to Gray Silty Sand
4.Date Well(s)Completed: Well ID# ft. . ft.
Sa.Well Loudon: ft ft.
Colonial Pipeline 1t. (L
Facility/Owner Name Facility ID#(if applicable) fL n
14511 Huntersville-Concord Rd ,t. ,t.
Physical Address,City,and Zip 21.REMARKS NOV 202i
Mecklenburg 01940102 REV 2
County parcel 7dentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
610775.085 N 1461415.603 W �r
Signature of Certified Well Contractor Dat
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(we're)constructed in accordance
with I SA NC,4C 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that
7.Is this a repair to an existing well: OYes or IJNo 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 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 multiple injection or non-Muter supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40'O (it.) 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@100') construction to the following:
31 .32 Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: (ft.) g
Ifwuter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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
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
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