GW1-2021-00379_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 40 ft' 70 ft' Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt*-easedweHs OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING( zeothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 35 ft- 2 in. SCh40 PVC
List all applicable well permits it.e.C ounw,State, I%artance,Injection,etc.J
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 ft. 70 ft. 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 30 ft- Portland Cem Tremie
Non-Water Supply Well:
ZMonitorina ❑Recovery 30 ft 33 ft Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft.
33 70 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain siu,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
12-19-20 MW-64 ft. ft.
4.Date Well(s)Completed: Well ID# -- e•
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/(honer Name Facility lD#(ifapplicable) ft. ft I"nil
-.�r�,y 6' Fla-tip!'..✓€•::.��
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. y'7a,T,-q ll
Physical Address.City,and Zip
21.REMARKS
Mecklenburg 2 x 2 Pad
County Parcel Identification No.(PIN) 8"FMC
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one lat/long is sufficient)
35.413329 N -80.804060 �_
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this lbrm, l hereby cern#,that the itell(s),vas(were)constructed in accordance
with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Ifell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the weAowner.
l/this is a repair.fill out known toell 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary_.
For multiple injection or non-water supply we//s ONLY with the same construction,you can
submit one.jnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdifjereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
/f it level is above casing,use"_ 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA & 2" SpOOnS 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.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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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 V
Revised August 2013