GW1-2021-00425_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLI':
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 26 ft. 28 ft. Wet
2973 fr. 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. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 fr. 26 ft. 2 in• SCh40 PVC
List till applicable well permits(i.e.County.Slate,Variance,Injection,etc.)
fr. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 26 tt. 28 ft. 2 in. .010 sch40 pvC
❑Geothermal(Hearin /Coolin Supply) ❑Residential Water Su ly(single) ft. ft. in.
g g PP Y) PP ( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rr• 22 rt. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
22 rt. 24 ft. Bentonite Chil 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 24 fr• 28 fr' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12-9-20 AS-03 ft. ft.
$)Completed: Well ID#
ft. fr.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ,
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. ,, r
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)
35.412731 N, -80.806410 N; ��,� • Z - 2
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this farm, I hereby cerli&that the we//(s)was(were)constructed in accordance
with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy q1 this record has been prorided to the well owner.
/J this is a repair,fill as knots n well construction inlbrmation and explain the nature of the
repair under 21 remarks section or an the back of 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
bier muhiple injection or non-water supply wells ONLY with the same construction,you can
submit one/orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-or nuuhiple wells list all depths ifdifjereni(example-3@200'and 2 cc 100') construction to the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
I/hater level is above caving,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 24a above, also submit a copy of this form ,ithin 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 ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of'Env iron men I and Natural Resources-Division of Water Resources Revised August 2013