GW1-2021-07697_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD Par intcmal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.
FRWATERwNES
ROM TO DFSCRIPITUN
Well Contractor Name
2907-A
NC Well Contractor Certification Number IS.OUTER CASING for mold-cased welts OR LINER'if a cable
FROM .TO DIAMETER TFtCKNFCC MATERIAL
S&ME Inc �• �- �•
Company Name 16.INNER CASING OR TUBING thermal cdosed•too
FROM TO I DIAMETER I THICtaVESS MATERIAL
2•Well Construction Permit#: +3 ft. 50 rt. 2 1O Sch 40 PVC
Lisl all applicable well permits#.&County,State,Variance,Injection,etc.)
ft. tL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSrZF TRICI IURS MATERIAL
❑Agricultural ❑MunicipaVl?ublic 50 ft 65 ft• 2 '010 Sch 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft It 1a
01ndustrialilCommercial ❑Residential Water Supply(ahared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
mirrigation 0 ft. 3 R. Grout Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 48 ft gentonite Pour
Injection Well: It. ti
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a (cable)
FROM TO MATERIAL EMPLACEMFN T METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 46 ft. 65 ft• #2 Sand Pour
❑Aquifer Test ❑Stotrnwater Drainage ft.CExperimental Technology ❑Subsidence Control
20.DRILLING LOG'attach additional sheets noes a
❑Geothermal(Closed Loop) ❑Tmeer FROM I TO DFK'RrPTrON 4obrb2n10 sMlfmckt e.graic size.dc.
oGeothermal(Heating/Coolin•Rearm) ❑Other(explain under 921 Ramadcs) 0 ft. 65 It. ;Red Brown to Gray Clayey Silt
9/9I20 MW-41 ft. ft'
4.Date Well(s)Completed: Well W# ft. fL
5a.Well Location: ft. fL
Colonial Pipeline rr. ft.
Facility/Owner Name Facility ID#(if applicable) fL
14511 Huntersville-Concord Rd
ft f` NO / 1
Physical Addmss,City,and Zip 21,REJISARKS
Mecklenburg 01940102 pev'.S-o
County Parcel Identification No.(PIN) !,
5b.Latitude and Longitade in degmes/minutes/seconds or decimal degrees: 22-Ce ficsdon: i
(if well field,one IaUlong is sufficient)
610493.441 N 1462185.803 W IQ&h j
Signature of Ccrtificd Well contractor Date t
6.Is(are)the well(s): 21ermanent or ❑Temporary By signing this farm,I hereby certify that the wel/(s)was(were)constructed in accordance
with 15A NC.fC 01C.0100 or 75A NCAC 02C.0200 Fell Construction Standards and that a
7.Is this a repair to an eldsdng well: ❑Yes or ®No copy ofthis record has been provided to the well owner.
If this a a repair,fill out knawn well rnnstruciinn information and explain the nature nj the
repair under#21 remarks section or on the back of tUr 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: 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 SUBMTTfAL]INSTUCTIONS
submit oneform.
9.Total well depth below land sw face• 65 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3(df200'and 2Qa I D0l construction to the following:
53.40 Division of Water ResourceN Information Processing Unit,
10.Static water level below top of easing. (D-)
Ifwaler level is above caring use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 .24b.For Iniecdon Wells ONLY: In addition to sending the form to the address in
(in.)
Auger 24aabove, also submit a copy of this fora within 30 days of completion of well
IL Well construction method construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resou
rces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 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 tieahh department of the county where
constructed.
I
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013