GW1-2021-07717_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 C
FROM To I nFscRlPnoly
Well Contractor Name ft. tt
2907-A
NC Well Contractor Certificstion Number M OUTER CASING for muld-cased webs OR LINER a licable
FROM TO DIAMETER TAICKNESS MATERiAI:
S&ME Inc ft. I in.
Company Name 16.INNER CASING OR TUBING,(Crethermal dosed-loop)
FROM TO DIAMETER I THfCRNTr4,S I MATERIAL
2.Well Construction Permit#: +3 R. 10 R• 2 In, Sch 40 PVC
List all applicable well permits(t.e.County,State,Variance,Injection,etc.) R. tt.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DtAMETER SLOT St L
2E 7WN.TOVFRS MA A
❑Agricultural OMtlnicipaV R. ft. In.Public 10 & 25 fL 2 In. 010 Sch 40 PVC
OGeothermal(Heating/Cooting Supply) CResidential Water Supply(single)
❑lndustrial/Commercial OResidential Water Supply(shared) le.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD AMOUNT
Olrri ation 0 R• 5 R• Grout Tremie
Non-Water Supply Well: 5 % 8 R• Bentonite Pour
mMonitoring DReeovery
Injection Well: R. ft.
OAquifer Recharge ❑Groundwater Remediation FROM D/GRAVEL PACK if A RIAL
r80M TO MATERIAL EMM.ACF.MBM METHOD
oAquifer Storage and Recovery ❑Salinity Barrier 8 fL 25 & #2 Sand Pour
OAquifer Test OStormwater Drainage & R
OExperimental Technology OSubsideaee Control 20.DRILLING LOG anach additional sheets If
❑Geothermal(Closed Loop) ❑TrRcer FROM TO DESCRrPTTON color,hardnesN v Vrock hpe.tMin 510t.ets.1
❑Geothermal(Hca:in 'Cooling Return) OOther(explain under#21 Remarim) 0 R• 2 R• Topsoil Organics
8/31/20 MW-10 2 M 4.5 R' Red Brown Sandy Clay
4.Date Well(s)Completed: wen HW 4.5 fL 20 R Red Brown to Gray Clayey Silt
Sa.Well Location: 20 R. 25 ft. PWR
Colonial Pipeline ft. tt.
Facility/Owner Nam Facility m#(if applicable) K ft.
14511 Huntersville-Concord Rd
ft. ft.
Physical Address,City,and Zip 21.REMABKS
Mecklenburg 01940102 Neva tan
Parcel Idcartification No.(PIN)
County
Sb.Latitude and Longitude In degrees/minutedseconds or decimal degrees: 27.Certification:
(ifwell field,one lavlong is sufficient)
610518.259 N 1461415.944 W
srgnauae of C rtifiad Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,l hereby cerq&that the well(k)was(were)constructed in accordance
with 75A NCAC 02C.0100 or 75A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E INo copy ofthis record has been provided t n the well owner.
If this is a repair,fill out known well cansrructinn informatian and explain the nature of the 23 Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide additional well site details or well
8.Number of wens constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same canstracdon,you can SUBN=AL INSTUCTIONS
submit one faro
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdi jerent(example-3 00'and 2®100� construction to the following:
10.Static water level below top of casing: NUA 00 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
8 (In.) 24b.For Inlectlon 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,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1&M
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 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 1eahh department of the county where
constructed.
I
Form OW-1 North Carolina Department of Environment and Natural Resources—Divieion of Water Resources Revised August 2013