GW1-2021-02700_Well Construction - GW1_20210514

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 dame 25 145 ft' Wet
2973
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. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 15 ft. 2 in. sch40 PVC
List all applicable well pernitt.s(i.e.Uoiorly,State, I%artmrce.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 15 f`' 45 f`' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in,
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 1 10 ft- Portland Cem Tremie
Non-Water Supply Well:
CZMonitorina ❑Recovery 10 fr 13 f� Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 r" 45 it #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ft. tr.
❑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/Cooling Return) ❑Other(explain under#21 Remarks) ft. fr.
2/24/21 MW-77
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: MAY
ft. ft 'VI H 1
Colonial Pipeline Company
Unl
Facility/Owner Name Facility ID#(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 I I v.c`(on
ft. rr.
Physical Address,City.and Zip
21.REMARKS
Mecklenburg 4"Stick up cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) �r
35.412725 N, -80.807561 W. ke" �
Signature of Certified Well Contactor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this form, 1 hereby certili,thin the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA ('AC 02C.0200 Well C'nn.siruction Standards and that a
7.Is this a repair to an existing well: ❑Fes or ElNo copy ofthis record has been provided to the wet/ou tier.
if this is a repair,fill out known well construction in/brmation and explain the nature of the
repair under-21 remarks section or on the back o/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 necessar}.
I-or multiple injection or non-water supply wells ONLY with the same construction,you can
submit one lorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 24a. For All Wells: Submit this form within 30 days of completion of well
1•or multiple wells list all depths tjdilfereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.► Division of Water Resources,Information Processing Unit,
it hater lerel 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 & 2" split spoons 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.field(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 Environment and Natural Resources—Division of Water Resources Revised August 2013