GW1-2021-00428_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 38 ft. 40 ft. Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LIVER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compann Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 38 ft. 2 in. sch4,0 pvc
List all applicable treh'permits(i.e.Counw,State, flarianc•e,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 38 ft' 40 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 34 It- Portland Cem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
34 f`• 36 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 36 f`• 40 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
12-6-20 AS-09 ft. ft. c
4.Date Well(s)Completed: Well ID# _, Ia 1' y •.,,
ft. ft.
5a.Well Location:
ft. It.
Colonial Pipeline Company ft. . ft. stH
Facility/Owner Name Facility ID#(ifapplicable) ft ft _ •�- r•�e��^;�t_!,lh
;•F;I:Y-�1 C:i1 d iJvv:�J te;
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft, ft.
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)
35.412477 N -80.805891 W
Signature of'Certified We 1-Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form, I hereby c•erltJi-that the trell(v) was(were)constructed in accordance
with I5A N'AC 02C.0100 or 15A N'A•02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cape gflhis record has been provided to the we/it owner.
//this is a repair,fill out known well construction information and explain the nature of the
repair under 21 remarks section or on the hack ofthi.s firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor nadtiple injection or non-tracer supph;tells ONLY with the same constructhm,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l-or andtp/e trells list all deptvs ifdi(fereni(example-3@200'and 2@1t10') construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
I/water level is above casing,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 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 w ere
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013