GW1-2021-00420_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 30 rt 33 ft' Wet
2973 ft. ft.
NC Well Contractor Cenification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal dosed-loo
FROM I TO I DIAMETER ITHICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 113 ft. 4 in- SCh40 I PVC
List all applicable well permits(i.e.Coumy,State,Variance,injection,etc.)
fr. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 rt. 33 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
❑Irri ation 0 ft. 9 fr. Portland Cem Tremie
Non-Water Supply Well:
M Monitoring ❑Recovery
9 ft 11 ft- Bentonite Chil Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S[ormwater Drainage 11 ft- 33 ft. #1 Sand Tremieft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/mck type,pmin size,etc.
❑Geothermal(Heating/Cooling ReMm) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-19-21 Well ID# RW-53
ft. ft.
5a.Well Location: ")_✓
Colonial Pipeline Company °-
ti
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 021
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. fr.
Physical Address,City,and Zip
2l.REMARKS
Mecklenburg �C;!c).
J, v
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)
35.413240 N -80.806108 W.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Hy signing this Jorm, /herehy certify that the we//(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: ❑Yes or E]No copy ofthis record has been provided to the well owner.
l/this is a repair,Jill out known well construction information and explain the natare of the
repair under=21 remarks.section or on the back gfthi.s form. 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-water supply wells ONLY with the saute construction,Yon can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 33 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For inninple wells list all depths#dillireni(example-3C200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
1/)water 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
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.
Forni G W-I North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 2013