GW1-2021-07751_Well Construction - GW1_20211116

i,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Thomas Whitehead FROM - - .70 DESCRIPTION
Well Contractor Name ft. ft. "
2907-A
NC Well Contractor Certification Number 15.OUTER CASING for multl eased wells O_ R.LINER f L liable
FROM TO DIAMETER TIHCKNFSS MATERIAL
SWE Inc ft ft. I is
Company Name 16.INNER CASING OR TUBING' eothermal closed-loo.
FROM To DIAMETER THICKNESS MATERIAL .
2.Well Construction Permit#: WM0301152 +3 20 n 2 in. Sch 40 "
List all applicable xrll permits(i.e.County,State,Variance,Infection,etc:) PVC
ft. ft. to
3.Well Use(check well use): 17.SCREEN
Water Supplly Well: FROM 'To DIAMETER SLOTSUE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 20 % 35 fL 2 in .010 Sch 40 PVC
OGeothertnal(Heating/Cooling Supply) ❑Residential Water Supply(single) fi iL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO - .MATERIALS EMPLACEMENT METHOD&AMOUNT : -
01trigation . 0 It.. 6 tp Grout
Tremie
Non-Water Supply Well: g 1. 18 it Bentoriite Pour
,EaMonitoring ORecovery .
Injection Wen fL (r
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK a licible.
- - -
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERUL. EMPLACEMENT METHOD18 it• 35 fL #2 Sand. Pour
OAquifer Test OStormwaier Drainage "
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets If-neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,Aaron" "soNrock qM Wafti eta
❑Geothermal(Heating/Cooling Return) OOther(e lain under#21 Remarks) 0 ft- 35 it. Red Brown to Gray Clayey to Sandy Silt
#9/8/20 MW-37 IL ft,
4.Date Well(s)Completed: Well ID .
it. tL
51L Well Location: "
Colonial Pipeline ft. ,t.
Facility/Owner Name Facility ID#(if applicable)
fL
14511 Huntersville-Concord Rd fL
f. rL
Physical Address,city,and zip 21.REMARKS l>"tom �� Spy i�11V.
Mecklenburg 01940102 REV 2
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell fold,one lat/long is sufficient)
610847.989 N 1461775.311 W jJcagr J J
Signature of Certified Well Contractor Date
6.IS(are)the wen(s): mPermanent or ❑Temporary By signing this.form,/hereby certify that the wsll(s)was(were)constructed in accordance
Kith 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that
7.Is this a repair to an existing well: ❑Yes or ElNo ropy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well consimclion information and exviain the nature of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
8.Number of webs constructed: 1 construction details. You may also attach additional pages if necessary:
For multiple injection or"non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well deptb below land surface: 35 (ft.) 24s. For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths jdifferent(example-3Q200'and 2Q1001 construction to the following:
26.90 Division of Water Resources,InforntatioD Processin Uni
l0.Static water level below top of casing:.. (ft.) g t,
lfwater level is above casing use"+" 1617 Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection 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.Wen construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man 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 Deparfinent of Environment and Natural Resources-Division of Water Resources Revised August 2013