GW1-2021-00432_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 37 ft. 54 ft. Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 "' 34 ft. 2 in. sch40 PVC
l.i,t all applicable well permits(i.e.County.State.Variance,Injection,etc,.)
ft. ft. in.
3."'ell Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal(Public 34 ft- 54 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Com mere ial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft' 29 ft. Portland Cem Tremie
Non-Water Supply Well:
29 ft- 31 ft- Bentonite Chi Tremie
OMonitoring ❑Recoven�
Injection NVell: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storm�vater Drainage 31 ft 54 ft- 1 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 12-23-20 Well ID# MW-66
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 02
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address:City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.413549 N -80.804759 W X4 ,, �L I i 3 a c
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing tht.s form I herehi,c•erit(i,that the we//(s) was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC•AU 02C.020t/Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gl7his record has been provided to the well owner.
//'this is a repair,fill out known well construction information and explain the nature of the
repair under--21 remarks section or an 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
l•'or multiple injection or non-water supply wells ONI Y vith the same construction,yin,can
submit one fbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 54 24a. For All Wells: Submit this form within 30 days of completion of well
hitr maniple wells list all depths ifdi/fereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 37 Ift,l Division of Water Resources,Information Processing Unit,
If water level is abore casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the cou ty where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013