GW1-2021-07715_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
Thomas Whitehead f
7ft.
TO DESCRIPTION
Well Contractor Name 2907-A ft.
NCWcIIComractorCertiScationNumbcr 15.OUTERC WG formalricasedwells OR LINER ire 6rable
lItOM TU DIO M$TER TFIICKNFCS It1ATFAIAI.
S&ME Inc ft. f I
Company Name 16.INNER CASING OR TIIBINGigeotbermal closed-loa
FROM TO DIAMLTEA I TRICKNESS MATERIAL
2.Well Construction Permit#: +3 ft. 24 m 12 Sch 40 PVC
List all applicable well permits,(i.e.County,State,Parlance,Injection,etc.) M in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT Si7E I TAIC'KNES9 I MATERIAL
❑Agricultural ❑Municipal/Public 24 ft- 39 n 2 In. .010 Sch 40 PVC
❑Geothemal(Heating/Cooting Supply) ❑Residential Water Supply(single) R R
❑lndustriaUCommercial ❑Residential Water Supply(shared) 16.GROUT
FROM TO MATERIAL FAIPLACEMErfr METHOD&AMOUNT
❑irrigation 0 ft. 3 it. Grout Tremie
Non-Water Supply Well: 3 ft- 21 R. BentOnite POUT
Monitoring ❑Recovery
injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SANMRAVEL PACK applicable)
FROM
❑Aquifer Storage and Recovery OSalinity Barrier fL TO fL MATE
21 39 #2 Sand EMPLACEMF Pour
MErHOD
our
❑Aquifer Test OStotmwater Drainage fL R
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional eheeh Hteeesu
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DOiCRIPTION telor,haMamwdur«►t rulesize.Ne.l
❑Geothemal(HeatinWCoo)ing Return) ❑Other(explain under#21 Remadcv) 0 % 5 ft. Red Brown Silty Clay
9/2/20 MW-15 5 % 39 ft. Red Brown Clayey Silt
4.Date Well(s)Completed: Well ID# ft &
Sa.Well Location: IL ti
Colonial Pipeline ft. (L
Facility/OwaorName Facility m#(ffapplicable) % R,
14511 Huntersville-Concord Rd fL I fL INUV 1 620
Physical Address,City,and Zip 2L REMARKS
Mecklenburg 01940102
County Parcel idcntif:cation.No.(PIN) r..`` I r j"r l,' u; t
5b.Latitude and Longitude in degreestmlautes/seconds or decimal degrees: 22.Cerdfication:
(ifwell field,one lat/long is safficieat)
610450.293 N 1461470.456 W b al
Si turc of Certified Well Coctlactor Date
6.Is(are)the wll(s): mPermanent or ❑Temporary in this form,1 he Gerd that Me.Tel s was
BY� 8 I +�' fy 1() (were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consrnrction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner,
!f[his is a repair,fill nut known well construction Information and explain the nature nf[he
repair under#11 remm*s section or on the back of this form. 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.
For multiple injection or non-waler supply wells ONLY with the same constmatlon,you can B NMAL INSTUCTION$
submit one form. q
9.Total well depth below land surface: �" ($,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjemni(example-3(a200'and 2®100') construction to the following:
10.Static water level below top of casing: 34.79 (it.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+' 1617 Mail Service;Center,Raleigh,NC 27699-1617
8 24b.For Julection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter. (In.)
Auger 24aabove, also subaut 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,otc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699 1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 daysofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Camlim Deuartmem of Environment and Natural Resources—Division of Water Resomccs Revised Augwt 2013