GW1-2021-00398_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 48 ft. 65 ft. wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L1NER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 25 ft. 4 in. sch40 pvc
List all applicable we//permits(i.e.County,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 25 ft. 65 ft' 4 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 ft. 17 ft- Portland Cem Tremie
Non-Water Supply Well:
IaMonitoring ❑Recovery 17 ft. 20 ft. BentoniteChil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 20 ft' 40 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUmck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft, ft.
4.Date Well(s)Completed: 12-2-20 Well ID# RW-48
5a.Well Location:
Colonial Pipeline Company 5
Facility/Owner Name Facility IDN(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. i ,orlatlon
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[at/long is sufficient)
35.413678 N -80.804922 w. ��� (� - t . & Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing thro'orm,1 hereby certifi,that the well(s)was(here)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Fes or Z1No copy of this record has been provided to the we//owner.
/'dais is a repair,fill out known trell construction information and explain the nature of the
repair under.21 remarks.section or on the back q/'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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l-or multiple injection or non-water.supply wells ON/Y with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- 65 24a. For All Wells: Submit this form within 30 days of completion of well
L•or multiple wells list all depths ifdi/)'&rent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 48 (ft.) Division of Water Resources,Information Processing Unit,
/'water lerel is above casing,use--" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA + 2" spoons construction
above, 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'Environnient and Natural Resources-Division of Water Resources Revised August 2013