GW1-2021-07719_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Ibis form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER Thomas Whitehead M
FROM TO I DFSCRIPIIUN
Well Contractor Name
2907-A ft. R
1FR5.00MU R ING formDIAMEYF/tO RR a ]cable
NC Well Contractor Certification Number
MATERIAL
SWE Inc
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
FROM TO DUMETER TAfCitSdSSS MATERUL
2.Well Construction Permit#: +3 R- 20 e. 2 In. Sch 40 PVC
List all applicable well permits(l.a County,State,Variance,Injection,etc.)
l4 ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNUS MATERIAL
❑Agricultural ❑MunicipallPublic 20 ft. 35 n. 2 to .010 SCT 40 PVC
❑Geothermal(Heating/Coaling Supply) ❑Residential Water Supply(single) R
❑Industrial/Commercial ❑Residential Water Supply(shamed) F GROUT
FROM TO MATF1t1A1. EMPLACFfiFENT METHOD 6 AMUUNT
0iffigation 0 R• 16 n• Grout Tremie
Non-Water Supply Well:
16 ft- 18 n• Berrtor►ite Pour
OMonitoiing ❑Recoveq
Injection Well: tc n
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK a llcable
FROM TO I MATERIAL I EMPLACEMFAM METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 R• 35 fL #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage % ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG tafts additional theeta if occurs
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRmTTON enter,hardom,eolVrad%#yM Zrale sire,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 IL 8.5 ft Orange Sandy Clay
8/30/20 MW-7 8.5 fL 16 ft. Brown Clayey Sand
Rr 4.Date Well(s)Completed: ell ID# 16 ft- 35 ft. Gray Silty Sand
Sa.Well Location: ft. >Z
Colonial Pipeline it. fL
Facility/Owner Namc Facility m#(if applicable) & &
14511 Huntersville-Concord Rd
F
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102 ,; iop) IO2;
County Parcel identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes)seconds or decimal d 22.Certification:
(610983 9m)87 N 1462042.726 W i
sigae tore of Certified weu eanuactor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,t hereby certify that the wells)mv(were)constructed in accordance
with 15A NCAC 02C.0700 or 15A NCAC 02C.0200 Well Cnnsmx-don Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has been provided to the will nwner.
If ibis is a repair,fill aul knowm well canstruciioa information and explain the nature of the
You mayy use
repair under#21 remarks section or an the back ojthis form. Y Site or additional well details:
Yose the back of this page to provide additional well site details or well
R 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 comerucdan,you can
submit onejorm. ��j SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �" (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths U different(example-3@200'and 2@1001 construction to the following:
10.Static water,level below,top of rasing: 31 .77 OL) 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 (in) 24b.For[election 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 well12.Well construction method- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
POR WATER SUPPLY WELTS ONLY: 1636 Marl Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
139.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 heakh department of the county where
constructed.
Form G W-1 North Carolina Department of finvuonment and Natural Resources-Division of Water Resourms Revised August 2013