GW1-2021-00418_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 57 ff 65 ft- I Wet
2973
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. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 35 ft- 4 in. sch40 PVC
Lisf all applicable well permits(i.e.County.Slate,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 35 ft' 65 fL 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 31 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 31 ft. 33 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft•
❑Aquifer Test ❑Stormwater Drainage 33 ft' 65 #1 Sand Tremie
ft. ft.
❑ENperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type.grain sire.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12-23-20 s)Completed: Well ID# RW-51 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company �-
P P Y e. e. �
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
MAR
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. Wail
1
Physical Address,City.and Zip 21.REMARKS -.r. urntion j-rr,' :''D
Mecklenburg Ott CV0i'
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)
35.413311 N -80.805491 W
Signs ure of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form, 1 hereby cerffh,that the see//(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or ONo copy ql/his record has been provided to the well owner.
U this is a repair/ill out known see//construction information and explain the nature ol'lre
repair under c21 remarks section or an the back q/'this/bra. 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 muhiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdiJjerem(example-3(:(�200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 57 (ft.) Division of Water Resources,Information Processing Unit,
//heater level is above casing,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 5/8 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
I3a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this font within 30 days ofcomple[ion of
13b.Disinfection type: Amount: well construction to the county health department of the county vhere
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013