GW1-2021-00397_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 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 a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name .16.INNER CASING OR TUBING(geothermal closed-lob
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft- 13 ft. 2 ia' SCh40 PVC
List all applicable well permits(i.e.County.Slate,Variance,Injection,etc.)
ft. I ft. I in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply AVell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 fL 28 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
El Irrigation 0 et•, 9 ft. Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recovery
9 ft 11 ft Bentonite Chil 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
❑Aquifer Test ❑Stormwater Drainage 11 ft- 28 fL #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,soilh—k type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
12-7-20 PV-08R
4.Date Well(s)Completed: Well ID# y
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft. �\ 1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. fr. yr t
Physical Address,City,and Zip -
21.REMARKS
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)
35.412703 N -80.805753 W. k6"
Signature of Certified Well Contractor Date
6.Is(are)the well(s): It7Permanent or ❑Temporary By.signing this form, I herebv certify that due we/1(s) was(were)constructer/in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy ofthis record has been provided to the well inviter.
I/this is a repair,./ill out known well construction information and explain the nature ojlhe
repair under=21 remarks section or on the hock ofthis/arm. 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-nrater supply wells ONLY with the same construction,You can
submit one./arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 24a. For All Wells: Submit this form within 30 days of completion of well
I-or nndtiple wells list all depdas il(different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
l/'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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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 201