GW1-2021-00416_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 ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable)
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' 30 ft. 4 in. sch40 PVC
List all applicable well permir.s(i.e.(bmrhC 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 30 ft- 50 r`- 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 rt. 25 ft. Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recover/'
25 r` 27.5 ft- Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GR4VELPACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f` f`
❑Aquifer Test ❑Stormwater Drainage 27.5 50 #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,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-13-21 Well ID# RW-49
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ff A 1 rJ 2
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. rt. F1
021
Physical Address.City,and Zip 21.REMARKS r I' vv.
Mecklenburg No cover ©`'10,
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)
35.413080 Nr -80.805753 w
Signature ofCeilified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this/orm, I hereby certify,that the we/1(s)was(were)constructed in accordance
i0th 15A NC'AC 02C.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 ofdris record has been provided to the we//corner.
if this is a repair,Jill out known well construclion information and explain the nature al'the
repair under:21 remarks section or on the back gf7his Jorm. 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.
Gor mudliple injection or non-waler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 24a. For All Wells: Submit this form within 30 days of completion of well
!or multiple wells list all depths ifdtfferent(example-3@200'and 2 u 100') construction to the Followin-:
10.Static water level below top of casing: None (rt) Division of Water Resources,Information Processing Unit,
U water lerel is above cosing,use"-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/6 with 2" split spoons 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.
Fotnt GW-I North Carolina Department of'Environment and Natural Resources-Division of Water Resources Revised August 2013