GW1-2021-00390_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
i
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if o cable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICI.I ESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 R. 2 in. seh40 PVC
list all applicable well perniilc(i.e.Uoumv,Slate.Variance,/trlec•lion,etc'.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 25 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 ft, Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery 6 ft. g ft- Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
$ rt. 25 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color•hardness,soil/rock type,gmin sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12-9-20 PV-01 ft. ft.
$)Completed: Well ID# ft. ft. _ r
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility lD4(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
,Physical Address City,y ty;and Zip 21.REMARKS
Mecklenburg No cover
County Pafeel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient)
35.412634 N -80.806396 W C,- UJ-1t)- ` . 13 •Z�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary By signing this Jorm,I herehy certifi•that the itell(s)was(mere)constructed in accordance
with I JA NC'AC 01C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
4 this is a repair,fill out known well conssiruction 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.
l-'or multiple injection or non-water supply wells ONLY with the same contraction,you can
submit one forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths if different(example-3 r@200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft.) Division of Water Resources,Information Processing Unit,
If water level is above 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 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 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 Revised August 2013