GW1-2021-00429_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 35 ft' 37 fL Wet
2973 ft. rr.
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. fr. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-lootil
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: 0 ft' 35 ft. 2 in. sch40 pvc
Lief all applicable u•el/pernnas(i.e.County,Slate, Fariance.hryection,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 fr. 37 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 31 ir. 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 if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier 33 it• 37 a• #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,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooline Return) ❑Other(explain under 421 Remarks)
AS-10
4.Date Well 12-5-20 s)Completed: Well ID# ft. it. ram•,�o v:� x 9 j>°Jy�'
5a.Well Location: tt. ft. ( a"
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 "' stZli
ft. ft. y r,,-.ir.p
n;
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 Iat/long is sufficient)
35.412585 N -80.805748 N, ��. �� (y� (3 • L`
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [ZPermanent or ❑Temporary BY signing this fhrm, I hereby certify that the well(s)was(here)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 EINo copy gfMis record has been provided to the we//owner.
I f this is a repair/ill ow knouw well construction i ilbrmaiion and explain the nature gf the
repair under=21 remarks section or on 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.
For multiple injection or non-irater.supply hells ONLY+rich the same construction,you can
submit one firm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3 a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
/(water level is above 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.NVell construction method: construction to the following:
(i.e.aueer,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 where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Waler Resources Revised August 2013