GW1-2021-07695_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal use ONLY:
11tis form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.
FROM TU DESCRIPITON
Well Contractor Name 1L [L
2907-A
NC Well Contractor CatiflcedonNumber 15.OUTER CASING formoltleasedweils ORIdNER If cable
FROM TO DIAMETER TIt1C1IN6SS MATERIAL
SAME Inc & ft. I in.
Company Name 16.INNER CASING OR TUBING c thermal dosed-loop)
FROM TO DIAMETER I TIITCKNUS I MATERIAL
2.Well Construction Permit#: +3 ft, 10 & 4 ID Sch 40 PVC
List all applicable well permits(i.e.County,Stale,Variance,Injection,eta)
<L !t.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO MAMMA %W store THICKNIM MATERIAL
❑Agticulttusl ❑Mtmicipal/Public 10 n. 50 tL 4 In. .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) &' IL
❑ludustrial/Commercial ❑Residential Water Supply(shared) lg.GROUT
FROM To__ MATEMLL F24PLACEMM METHOD&AMOUNT
CIrrigation 0 n. 6 ft. Grout Tremie
Non-Water Supply Well:
❑Monitoring ORecovery 6 R' 8 ILBentofllte Pour
Injection Won: n. ft
❑Aquifer Recharge ❑Grvumtwater Remediation 19.SANDIGRAVEL PACK(if ble
OAquar Storage and Recovery ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ty 8 n• 50 n #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage % n.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG attach additional aheda If aceeasa
❑Geothemid(Closed Loop) ❑Tracer FROM TO UFtMIMOx color,herdan%tgrark type.grain sloe.err.
❑Geothermal(HeatinWCooling Return) ❑Other(explain under#21 Remarks) 0 % 50 ft. Red Brown to Gray Sandy Silt
9/21/20 RW-32 % "
4.Date Well(s)Completed: wt v ID# R.
Sa.Well Location:
Colonial Pipeline n. it.
Facility/Ow=Namc facility 1D#(ifepplicable) K IG
NQVI
14511 Huntersville-Concord Rd n. ft.
Physical Addrewc,City,and Zip 2L REMARKS
Mecklenburg 01940102 ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,a=laMong is sufficient)
610887.01 N 1461973.617 E W �� s> o ,a 6 �►
Signature of Ccruficd Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing thin form,I hereby certify that the—11(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or l SA NCAC 02C.0200 Well Construction Srandmds and tlwr a
7.Is this a repair to an existing well: ❑Yes or PJNo copy of this record has been provided to the well owner.
If this 0 a repair,fdl out known well construction infornmllon and explain the nature of the
23.Site m or additional well details:
repair under#?/remarks section or on the back of rhfs form. diagram
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 infection or non-xater supply wells ONLY wilh the same construction,you can
submit one form. SUBMITTAL INSTUCTTONS
9.Totsl well depth below land surface: 50 (ft.) 24a For All Wells: Submit this form within 30 days of completion of wen
For multiple wells list all depths ifdiJjerent(example-3(ay200'and 2®100� construction to the following:
10.Static water level below top of casing: N/A 00 Division of Water Resources,Information Processing Unit,
If water level is above rasing use-t" 1617 Mail Service�Center,Raleigh,NC 27699-1617
11.Borehole diameter. 10 (in.) 24b.For Injection 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,cte.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Merl Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13s 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 ihealth deportment of the county where
constructed. I
Form CW-1 North Carolina Department of Environment and Natural Rom"--Division of Water Resources Revised August 2013
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