GW1-2021-00392_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White14.WATERZONES
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 a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compan}Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 to ft. 2 in. sch40 pvc
List all applicable trell permits(i.e.Uoun(v,Stale,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 10 ft' 25 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f`' f`' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 6 ft Portland Cem Tremie
Non-Water Supply Well:
�Man itori ng ❑Recovery
6 f` 8 f` Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 f` 25 f` #1 Sand Tremie
❑Aquifer Test ❑Stormwater 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 e, rain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12-8-20 s)Completed: Well ID# PV-03 ft. ft.
ft. ft. _
�9
5a.Well Location: ft. ft. e
Colonial Pipeline Company ft. ft. _
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City, u y �} •,(�y ry,and Zip 21.REMARKS
-.,q n 3�17
Mecklenburg No cover
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)
35.412339 N -80.806358 w.
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hr,signing this farm, 1 hereby cerliht that the trell(s) vas(here)constructed in accordance
,s ah 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofrhis record has been provided to the[tell owner.
4 this is a repair,Jill out known trell construction inlormation and explain the nature of 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fier multiple injection or non-[ruler supply yells ON/Y u itn the same construction,you can
submit one farm. 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 multiple wells list all depths tjdi/ferem(example-3 a 200'and 2 r@i 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
Y 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 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 Em�ironnuent and Natural Resources-Division of Water Resources Revised August 2013