GW1-2021-07728_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:
Thomas Whitehead 14.WATER ZONES
FROM I TO DESCRU'11UN
Well Contractor Name ft. ft.
2907-A & ft.
NC Wcll Contractor Ccrtificadon Number IS.OUTER C RLG for mniti-eaaed wells OR LINER a ble
FROM TO D?AME7'HR TIIICIO`E.iS MATBRIAI.
S&ME Inc f. I 'n
Company Name 16.INNER CASING OR TUSI1tiG thermal closed400
FROM TO DIAMETER TMCKNUS MATERIAL
2.Well Construction Permit#: t3 19 & 2 In. Sch 40 PVC
Litt aft applicable wail permits(r.e County,State,Variance,Infection,etc.) lL ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETPA I SLOT SIZE E TRICKN 5 I MATERIAL
19 34 R 2 A70 Sch 40 PVC
❑Agricultural ❑MrnicipaVPublic & ft
❑Geothermal(Heating Cooling Supply) ❑Residential Water Supply(single)
❑IndustriallCommemial ❑Residential Water Supply(shared) F GROUT
RUM I 7U MATFdUAI, EMPLACEMENT METHOII&AMUUNT
❑kri.atiorm 0 rL 15 % Grout Tremie
Non-Water Supply Well: 15 17 fL Bentoriite Pour
amonitoring ❑Recovery
Injection Well: n a
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK lleMe
FROM TO MATERULL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier 17 iL 34 f►. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage R R
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional abeets If s eansa
❑Geothenwl(Closed Loop) ❑Tracer FROM I TO MCRIPTION color,hardness,sol0roek r. e,prain r ate.)
❑Geothermal(Healing/Cooling Return) ❑Other(explain under#21 Remadcs 0 R 123.5 ft- Brown Sandy Clay
8/25/20 MW-2 23.5 R- 34 ft. Light Gray Silty Sand
4.Date Well(s)Completed: Wen D?# ft. ft.
5s.Well Location: ft. ft.
Colonial Pipeline ft. f<.
Facility/Owner Name Facility m#(if applicable) tt ft.
14511 Huntersville-Concord Rd R.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 01940102Vi5;0.,
County Parcel Ideniiflcation No.(PIN)
5b.Latitude and Longitude in degreesiminates/seconds or decimal degrees: 22.Certification:
(ifwell Geld,one lat/long is sufficient) 1
610823.419 N 1461424.282
Sigrti _- of ed Well Contractor Date
6.Is(are)the well(s): mPermanent or ❑Temporary By signing this form,1 hereby certify thai the well(s)was(were)Constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consmuction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this retard has been provided to the well owner.
If this is a repair,fill out known well construction information and explain die nature of the 23.Site diagram or additional well details:rrpair under#11 remark section or on the back gf this farm.
You may use the back of this page'to provide additional well site details or well
0.Number of wells constructed: 1 construction details. You may also attach additional pages ifneccssary.
For multiple infection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit onefonn.
9.Total well depth below land surface: ��'0 (fL) 24s. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depihs ifdii ferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of erasing: 29.57 (fL) Division of Water Resources,Information Processing Unit,
lfwater level is above casing use"+" 1617 Mail Service eenter,Raleigh,NC 27699-1617
II.Borehole diameter: 8 (ln.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Auger 24a above, also submit a copy of 4his form within 30 days of completion of well
12.Well oonslruction method: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resourees,1 Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994 636
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 halth department of the county where
constructed.
Form GW-1 North Carolina Deparatnent of Envirotmrent and Natural Ravutucm-Division of Water Reaomces Revived Augttvt 2013