GW1-2021-07716_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
nds form can be used for single or multiple wells
1.Well Contractor Information:
Thomas Whitehead 14.WATER ZONES
TO DFSCRIC110N
Well Contractor Name ft-
t ft.
2907-A FROM
NC Well Contractor Certification Number 15.OUTER CASING'for mul fL I
Heaaed wells OR LINER it a livable
FROM TO DIAMHTFR I KATERIAL
SWE Inc fL I fL in.
Company Name 16.INNER CASING OR tothermal closed-too
FROM TO 107AMEFER 77ItCfiNM MATERIAL
2.Well Construction Permit#: 0 ft. 20 It. 2 I° Sch 40 PVC
LW all applicable%ell permits(ie.County,State,Variance,Injection,etc.) ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT BUZ T MCKNEas MATERIAL
OAgriculwral ❑Mtmicipal/Public 20 fL 40 fL 2 In. .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft la
❑lndustriaUCommetcial ❑Residential Water Supply(shared) IL GROUT
FROM TO MATERIAL MPI.ACEMENI'METHOD&AMOUNT
01ni lion 0 It- 17 R Grout Trernie
Non-Water Supply Well:
Monitoring
❑Recovery 17 ft• 18 ft- Bentoriite Pour
Injection Well: ft ft.
❑Aquifer Recharge ❑Granmdwater Remediation 19.SAND/GRAVEL PACK if a cable
FROM TO MATERIAL EMPIACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 40 It• #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. fit
OExperimental Technology ❑Subsidence Control 20.DRILLING L att■ addlduttal sbects if viemsa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP770\ color,hardens,willrock e, io s&e.ete.)
❑Geothe1ma1(Heating/C Return) ❑Other(explain under#21 Remarks) 0 R• 3 ft, Dark Brown Clay
$/27/20 MW-12 3 fL 38 % Ught Brown Clay
4.Date Well(s)Completed: Wen ID#
Sa.Well Location:
Colonial Pipeline n. a
Facility/OwwrNamc Facility m#(ifapplicable) ft. ft.
14511 Huntersville-Concord Rd rL ft.
Physical Address,City,and Zip 21,REARKS
Mecklenburg 01940102 M �eV,y;
County Parcel Identification No.(PQdy
5b.Latitude and Longitude in d minates/seconds or decimal degrees:
� �� Z2.Cerii tcation:
35 41455LS sufficient) -80.80797 W ^ -e maea104
a!
N --
gnatutc of Ctxtifiod Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the wef/(s)xns(were)onruiructed in accordance
with 15A NCAC 02C.0100 or 1JA NCAC 02C.0200 Well Consmiction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E)No copy of this record has been provided to the well owner.
If this is a repair,fit out known well canstnretlon lnformadan and explain the nature of the
re pair ander#21 remarks nxt4 on or on die 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
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 SUBMMAL INSTUCPIONS
submit unefurm.
40.94 24a. Eor All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: (K•)
For multiple wells list all depths Jd{Q'erent(ex mp/e-3 00'and 2Q100') construction to the following:
10.Static water level below top of casing: �A 00 Division of Water Resources,Information Processing Unit,
If water level is above casing use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
8 24b.For lection Wells ONLY: In addition to sending the form to the address in
(iD-)
Auger 24aa�ve, 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,direct push,etc.) 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 At Injection Wells:
Also submit one copy of this form within 30 days of completion of
13L Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
Form GW-1 North Carolina Deparement of Euviromnent and Natwal Resources—Division of Water Resources Revised August 2013