GW1-2021-07703_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single ar multiple wells
1.Well Contractor Information:
Thomas Whitehead M WATER ZONES
FROM TU DESCRIPT[UN
Well Contractor Name R R.
2907-A IL
NC Well Contractor Certification Number 15.OUTER CASING or mulEl•cased webs AR-LR'ER If a llcable
FROM TO DIAMETER TNIClOHF.SS MATERIAL.
S&ME Inc R tz I i..
Company Nam 16.INNER CASING OR T UDIRNG eothermal closed-too
FROM TO DIAMETER TMCKNESS I MATFRLAL
2.Well Construction Permit#: t3 fL 10 R 2 In. Sch 40 PVC
List oil applicable well permits(i.e.County,State,Variance,Iryecdon,e(c.) 2 It. in.
3.Well Use(check well use): 17.SCREEN
Water supply well: FROM I TO DIAMETER SLOT SIZE TRICKNFM MATEWAL
❑Agricultural ❑Municipal/Public 10 R. 25 fL 2 .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R R' ro
❑Industrial/Commercial ❑Residential Water Supply(shared) Ill.GROUT
FROM I TO MATSRUL F"t ACFINENT METHOD&AMOUNr
01ni ation 0 ft. 6 R. Grout Tremie
Non-Water Supply Wells:
Bentonite Pour
amonitoring ❑Recovery 6 R. 8 ft.
Injection Well: R 2
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK able
uifer Storage and Recovery ❑Salmi Barrier FROM To IAATERIAL EMPIACEMENT METHOD
❑
g ty 8 R- 25 R. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
R. R.
❑Experimental Technology ❑Subsidence Control
20. LING LOG attach additional sbects:K necessa
❑Geothermal(Closed Loop) ❑Tracer MIN I TO DUMIMON color hardn sAVr"L t. to stw'ce
❑Geothermal(Heatin C'•ooiin Retum) ❑other(Whin under#21 Remarks 0 It. 8 R. Brown Clayey Silt
9/6/20 MW-33 8 R- 14 R. Gray Sandy Clay
4.Date Well(s)Completed: even ID# 14 R- 15 ft. Gray Brown Silty Sand
5a.Well Location: 15 R. 25 R. Gray Sandy Silt
Colonial Pipeline �, lL
Facility/Owner Name Facility M#(ifapplicable) ft. %
14511 Huntersville-Concord Rd
rt 2
Physical Address,City,and Zip 2L REMARKS is
Mecklenburg 01940102 e ;d ,
County Parcel Identification No.M t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cc tion:
(if well fiel(l,one latAong is sufficient) l J(t
611254.113 N 1461864.564 W
Signature of Certified Well Co r Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form,I hereby codify that the aell(s)was(were)constricted in accordance
with IJA NCAC 02C.0/00 or 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well n vner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks section or on the back of this farm. 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: 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 onefurm. SUBMMAL INSTUCTIONS
9.Total well depth below land surface: 2"5,�'jj (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel&list all depths if different(example-3 00'and 2@100) construction to the following:
10.Static water level below top of casing: 13.2 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 8 (ia) 24b.For Inledlon 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,dived push,etc.)
Division of Water Resources,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: construction to the county health 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