GW1-2021-00433_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple swells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 39 t" 48 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LINER:ita licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING.(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 33 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.Counw,,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33 f`' 48 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt• 28 ft. Portland Cem Tremie
Non-Water Supply Well:
2Monitoring ❑Recovers' 28 fL 31 fL 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
31 f`• 48 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach 2ddi6on2l'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ff. ft. �'�Y=;� �'� •,3 �`°,J
4.Date Well 12-20-20 s)Completed: Well ID# M V V-70
tt. ft.
5a.Well Location: ft. ft' NIAR 15 2021
Colonial Pipeline Company ft. ft. _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. " v""�`•.; ' i vL '
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address.City,and Zip
21.REMARKS
Mecklenburg 8°FMC
County Parcel identification No.(PIN) 2 x2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
35.413302 N -80.804380 W. �, t •Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form, I herebv cerul. that the we//(.$)was(were)consirucied in accordance
wish 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Con.struclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or El No copy q1 this record has been prorided to the a-ell owner.
I/Phis is a repair,fill out known well construction in%rmation and explain the nature o(the
repair under=21 remarks section or on the back q/7his 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 maliiple injection or non-wafer supply uel/s ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 48 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel/s list all depths ifdi1jerent(example-3 to 00'and 2 tt 100') construction to the following:
10.Static water level below top of casing: 39 Division of Water Resources,Information Processing Unit,
4 water lere1 is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA & 2" spoons construction
above, also submit a copy of this form within 30 days of completion of well12.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 otEnvironment and Natural Resources-Division of Water Resources Revised August 2013