GW1-2021-07696_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For ldcrnal Usc ONLY:
This form can be used for single or multiple wells
1.Well Conumetor Information:
Thomas Whitehead W14.
ATER FROM
TO XUPTION
RZONES
Well Contractor Name ft rl
2907-A IL I Ft.
NC Well Contractor Ccrtification Number 15.OUTER CASING multi vued well OR LINER If a cable
FROM TO MAMLETER 7'111CKNESs MATERIAL
S&ME Inc fL
Company Name 16.OMER CASING OR TDBING' " thermal closed-loo
FROM TO DIAMETKR I THUCKNE.SS I MATEatAL
2.Well Construction Permit#. +3 ft. 11 ft. 4 1O Soh 40 PVC
L&I all applicable well peanuts(i.e-County,State,Parlance,fnjerdnn,etc.)
ft. tL ia.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMtsM I SLOT SEM I TMCKNMS I MATERIAL
❑Agriculturat ❑Mtmicipal/Public 11 ft. 46 ft 4 to .010 1 Sch 40 PVC
❑Geothermal(Heatmg/Cooling Supply) ❑Residential Water Supply(single) ft ft I In
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROAT.
FROM TO MATERIAL EMPLACFINENT METHOD&AMOUNT
Ohri ation 0 fL 6 R Grout Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
6 & 8 ft- BentonitePour
Injection Well:
OAquifer Recharge ❑Groundwater Remediation 19.SAMDIGRAVEL PACK Of Oplitable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Satinity Barrie g ft• 46 � #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Contra[
20.DRELLING IAK attacb addidupal sheets if nceessa
❑Geothermal(Closed Loop) ❑Tracer FR04M I TO DESCRrP'nO%I tobt.bardaes soivrmkr radar ete
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 R madcs) 0 % 40 R Gray brown Silt
9/15/20 MW-48 40 fL 46 ft. Gray Silty Sand
4.Date Well(s)Completed: Well ID# R. ft.
Sa.Well Location: ft. R.
Colonial Pipeline & ft.
Facility/OwncrNamc Facility ID#(if applicablc) fL ft.
14511 Huntersville-Concord Rd ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102 R v ;o. I
County Parccl Idcntiflcation No.(PINJ 1 "
5b.Latitude and Longitude In degrees(minote-Jseconds or decimal degrees: 2L Ce . ation:
(if well field,one lat/long is sufficient) �ls]
610606.396 N 1461638.047E W
Signature of Certified Wcu Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary signing this arm,1 here certify that the wells was By tgnt g j by fy () (were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or EINo copy of this record has been provtrfed to the well owner.
If this is a repair,fill nut known we/1 construction infnrmadon and esplain the nature of the
repair under#11 remarks section or on the back of this fora. 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 if necessary.
Fnr muhiple injection or note-water supply wells ONLY with the same construcdon,you can
submit oneform SUBMTITAL INSTUCTIONS
9.Total well depth below land surface' 46 (H,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(emmp/e`-3' Du'and 2Qa I001 construction to the following:
V
10.Static water level below top of casing: l /A 00 Divlslon of Water Resources,Information Processing Unit,
If water level is above rasing,use"+" 1617 Mall Service Center,Raleigh,NC 276994617
11.Borehole diameter: 10 (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.augor,rotary.cablo.diroct pustt,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(0m) 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 G W-1 North Carolina Department of P.nvironnwnt and Natural Resources—Division of Water Resources Revised August 2013