GW1-2021-00426_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
F
TODESCRIPTION
Well Contractor Name ft• 35 ft. Wet
2973 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING formulfi-cased wells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 f" 33 ft. 2 in. sch40 pvc
/,i.st all applicable+cell perm os(i.e.CoioriV Stale, Variance,htrec•lion,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 33 ft- 35 ft' 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 29 ft. Portland Cem Tremie
Non-Water Supply Well:
fZJMonitorine ❑Recover
29 ft 31 ft. Bentonite Chi Tremie
Injection Well: rt. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 31 ft• 35 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage " ft.
❑Experimental Technology ❑Subsidence Control ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack ry e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
rt. ft.
4.Date Well 12-8-20 AS-06s)Completed: Well ID#
5a.Well Location: ft. ft. FRI,
Colonial Pipeline Company
Facility/Owner Name Facility ID9(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 s=rec��s si+is, dui
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:
(if well field one lat/long is sufficient)
35.412317 N -80.806364 N. CA�-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): I231"ermanent or ❑Temporary He signing this/arm, I hereby sera&that the wel O vas(here)constructed in accordance
Will,IJA 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 El No cony gfilits record has been provided to the well owner.
It this is a repair/ill out known well construction inJhrmalion and explain the nature of the
repair under=21 remarks section or an the back of this Jarm. 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.
Ivm multiple injeclion or non-waler.supply wells ONLY it ah the same construction,You can
submit one./arm. 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
hor multiple wells list all depths iJdiJJereni(example-3 cJ 00'and 2 a/00') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
I/'water level is abore casing use- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection 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 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 clays ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county t ere
constructed.
Form GW-I North Carolina Department of Envimmnent and Natural Resources—Division of Water Resources Revised August 2013