GW1-2021-07748_Well Construction - GW1_20211116

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
7M form an be med for'sinale or muhiple wells
I.Well Contractor Information:
Thomas Whitehead r14.WATFRZONIUS
FROM TO OKSCRIMON
well coalnator Name n. A.
2907-A n.
NC Well Contractor Ceniftcation Number 'IS:OUTER CASING ter atahFeatud web OR LINER a abk !
-FROM- TO -DIAMETER .1HICKNESS MATERIAL
SWE Inc n. rt. In:
ComliatyName 16.INNER.CASINGORTUDING eotbertnelelawd400
FROM TO DIAMETER TIIRCKPrFSS MATERIAL
2.Well Construction Permit N; . +3 IL 27 rt. 2 In-j Sch 40 PVC
Llrr all aWleable Mel/permits(Le.County,State,l orfance,Infection,etc.)
rt.' ft. In,
3.Well Use(check well use): 11.SCREEN
Water Supply\\'ell' FROM TO: DIAaIETER BLOT SIZE THICKNESS MATERIAL ..
OAgrieultural OMunicip■UI'ublie 27 rt 37 2 In ;.010 Sch 40 PVC
OGeotherrul(Heating/Cooling Supply) Mesidential Water Supply(single) n re In
OlndustriaVCommeriiel OResidcntial Water Supply(shared) 1&GROtIf
FROM. . To I MATERIAL I EMPLACEMENTINLTVIOD&AMOUNT
Chri lion 0 n• g rt• Grout Tremie
Non-Water Supply Well:
Monitoring ORccovery 6 rt. 25 eentonite Pour
Injection Well: rt'
OAquifer Recharge OGroundwater Remediatico If.SANDIGRAVEL TACK ■ Iable s —'-
.FROat TO MATERIAL EMMCEMEKT METHOD -
OAquifer Storage and Recovery (]Salinity Barrier 25 rt 32 rL 012 Sand Pour
❑Aquifer Test OStormwaterDrainage
OExperimental Technology OSubsidence Control
d0.DRILLING LOG Numb addide■al sbeeb Uneresa r
OGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION IaW a.Waeaa»IVrock tjw,Vale Else etc),
13Geothermal(Heating/Cooling Return) ❑other(el lain under#21 Remarks 0 ¢. 37_ fL Red Brown to Gray Clayey Silt
4.Date Well(s)Completed: 9./9/20 Wd11Dq MW-4�
n. a
Sec.Well Loestlon: rL ft.
Colonial Pipeline n
Facility/OwncrNatnc Facility 110(ifappliatile) rt Nov fL f
13900 .Huntersville-Concord Rd
Physical Addrem City.and 4 21:REMARKS: _
Mecklenburg 01921204 fir;o .�
County Peal tderttifiation No.(PRO
Sb.Latitude and Longitude in degreesiminuteslsecouds or decimal degrees: 22•Certification:
(1ar:I1 field;ane UVbng is sufficient)'
610244.764 N 1461670.079 w 14 t' /to A/�I
Signature urCcnrfted Well Contractor Date
6.Is(are)the weil(s)t OPermenent or (]Temporary Sy signing this form.I hereby cenVy that the weft(s)Mur(awl)coartrveted in accordance
Milh 15A NGC o2c.oloo or 15A NCAC 01c.0100 Wt11 Comourdon Sipndards and that e
7.Is this a repair to an existing well: OYes or ON* ropy ofthis record has been provided to the wellownei.
lfthtr is a repglr,fill out beam well cenrouction information and aplain the nature of the
repair under M21 remarit section or on the back ofthlsforin. 23.Site diagram or add)tioual well details:
You may use the back of this page to provide additional well site details or well
g.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple lnfecdon or non•twater supply wells ONLY with the same contraction,you can
submitaneform, 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 ud/t list all depths iirdiffereet(erample-3Q200'ond 2@100') construction to the following:
33.25 Division of Water Resoarees,loformadoo Processing Unit.
if Static wafer level below lop of rasing: (fL) 1617 Mall Service Center Raleigh,NC 276"4617
1Jaarer(eve!b above easing;use"*" r
11.Borehole diameter: 8 (in.) 24b For Inleetlon 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.■ugd,rotary,able,direct push.eta.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
I3a.Yield(gpmj Method of test: 24c.For Water Supply&Injection.Wells:
Also submit one copy of this form within 30 days of completion of
13b.DI■IDfecdon type: Amount: well construction to the county health'department of the county where
constructed.
Form GW-1 Noah Catolins Department of Environment and Natural Resources-Division of Wetcr Resouiecs Revised Aujuut 2013
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