GW1-2021-07714_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For lntcrmtl Use ONLY:
ILis form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead M.WATER ZONES
t
FROM TO I DFSCRIPIIUN
Well Contractor Name
2907-A ft. I
NC Well Contractor Certification Numbcr 15.OUTER CASING for malti-caaed iwells OR LLNER if a ileable
FROM TO DiAMETFR 7lI1CKN6SF MATERIAL
S&ME Inc ft. ft.
Company Name 16.INNER CASING OR i QBING hernial dosed-loop)
FROM TO DIAMETER TlIiCRNBSS MATERIAL
2.Well Construction Permit#: +3 ft• 30 & 2 ID Sch 40 PVC
LL91 all applicable well permits(i.e.Cmmty,Slate,Variance,lryection,etc.)
ft. R. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TD AMETER, SLOTSTZE 7AICI NE&S MATERIAL
❑Agricultural OMtmicipal/Public 30 fL 45 �!T=t-' 010 SCh 40 PVC
1.
❑Geothermal(Hen ft.
(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑IndustriaVCommemial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri gation 0 ft. 3 ft Grout Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
3 ft- 27 � Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACKN a le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R. TO R. KATFA UL EMPLACEMENT METHOD
27 45 #2 Sand Pour
OAquifer Test ❑Stormwater Drainage ft. ft,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additioiud sheets if neeessa
❑Geothermal(Closed Loop) ❑Tnuxr FROM To DMCRIPTION(color,hardoem mNrock e, etc
❑Geothermal(HeatinWCooling Return) ❑Other(explain under#21 Remarks)J 0 ft. 6 ft. Red Brown Silty Clay
9�2�20 MW_1 g 6 (L 15 ft. Red Brown Clayey Silt
4.Date Well(s)Completed: Well ID# 15 ft- 45 It. Gray Silty Sand
Sn.Well Location: ft. ft.
Colonial Pipeline ft. iL
Facility/Owner Na ac Facility UM(if applicable)
14511 Huntersville-Concord Rd ft.ft' fL
ft
Physical Address,City,and Zip 2L REMARKS
NOV I
Mecklenburg 01940102 Rom„ ,o'n J
County Parcel Identification No.M
1"
5b.Latitude and Longitude in degrees/minmtes/sernnds or decimal degrees:
22.Certifi lion:
(if well field,one lat/long issufficient) L v•i,'
610817.943 N 1462185.479 W
S_ature of Ccr ifiod Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)consoucied in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consrmcdoa Standouts and that a
7.Is this a repair to an ezisting well: ❑Yes or ®No copy afthis record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature afihe
repair under#21 remarks section or an the back of thisform. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same consirwelion,you can
submit one farm. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 45 yt) 24a. For All Well Submit this from within 30 days of completion of well
For multiple wells list all depihs if different(example
�-33 200'a g:
nd 2®100� construction to the following.
10.Static water level below top of easing: 39'78 00 Division of Water Resources,information Processing Unit,
lfwater revel it above caring,use + 1617 Mail Service'Center,Raleigh,NC 27699-1617
I1.Borehole diameter. 8 (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
IL Wall 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 276994636
24e.For Water Supply&Injection Wells:
13a.Yield(gpmj 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`heahh department of the county where
constructed.
Form G W-1 North Carolina Deparoment of Envnontceat and Natural Resources—Division of Water Resomccs Revised August 2013