GW1-2021-07745_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 TO - DESCRIPTION
Welt Contractor Name fL ft.
2907-A fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells) LINER f a 'RcaMe
-FROM TO DIAMETER "THICKNESS .. MATERIAL
SWE Inc fL fL. in.
Company Name 16.INNER CASING OR TUBING(peother &I closed-loop)
WM0301152 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +3 R- 27 R• 2 in. Sch 40 PVC
List all applicable well permits(1.e.County,State,Variance,Injection,etc:) ft. ftIn
3.Well Use(cbeck well use): 17.SCREEN
Water Supply Well: - FROM TO -- DIAMETER SLOT SITE THICKNESS MATERIAL..
❑Agricultural ❑Municipal/Public 27 h 37 tL 2 In. .010 SCh 40 PVC
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R• f• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Elltrigation - 0 k• g & Grout Tremie.
Non-Water Supply Well: g 25 ft Bentonite Pour
IaMonitoIring ❑Recovery
Injection Well: ft. . fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK• a lleable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO . . MATERIAL EMPLACEMENT METHOD25 fL 37 fL #2 Sand Pour.
OAquiferTest ❑StormwaterDrainage tL "
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If.necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,herdn soiltrock type,grain etc.)"
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) 0 fL 37 & Red Brown to Gray Clayey Silt
4.Date Well(s)Completed: 9/9/20 Well ID#MW-40 ft. fLft. tL
Sa..Well Location: it. ft
Colonial Pipeline
Facility/Owner Name Facility ID#(if applicable) ft. it. 6 n2 NOV i
13900 Huntersville-Concord Rd ft, fL U 1
Physical Address,City,and Zip
21.REMARKS uJ1V
Mecklenburg 01921204 REV z�r• qMATION PROCESSING
County Parcel'Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaMong is sufficient)
610244.764 N 1461670.079 W
rgnature of Certified Well Contractor Date
6:Is(are)the well(s): OPermanent or ❑Temporary By signing this form.I hereby certify that the Nell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A 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 to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks 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-xuter supply wells ONLY with the same"construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:.37 (ft.) 24a. For All Wells: Submit this'.form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a@200'and 2@100) construction to the following:
33:25 Division of Water Resources,Information Processing Unit,
10.Static water below top of casing: (ft.) �
Ifwater level is above casing use"+^ 1611 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Auger24aabove, 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&Injection'Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013