GW1-2021-02720_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 Name 23.5 rt• 37 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. I in.
Company Name 16.INNER CASING OR TUBING e6thermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 17 f- 2 in. sch40 PVC
List all applicable well perndrs(i.e.C'ounty,Sane, Variance,Injection,etc.) - ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 f' 37 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIv f. f. in,(sin le)❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 10 ft- Portland Cem Tremie
Non-Water Supply Well:
OManitoring ❑Recovery
10 rt• 15 rt• Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 15 ft- 37 ft. #1.Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fr. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifAccessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 3/2/21 MW-80 ft. ft.
Completed: Well ID# ft. ft. t�
5a.Well Location: fr. tr. E E
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. Information Processing Unit
Physical Address,City,and Zip 21.REDIARVS DVVR Section
Mecklenburg 4"Procover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
35.412182 N -80.806945 W
Signature of ertitied Well Connac r Date
6.Is(are)the well(s): (OPermanent or ❑Temporary
Hv signing this fiirnt, !hereby ceniJv that the well/+)it-as(were)constructed in accordance
It'ith 15A NCAC 02C.0100 or 15.4 NC'AC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature oj'the
repair under 721 remarks section or on the hack ofthis%arm. 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.
Fbr multiple injection or non-water supply wells ONLY u•ilh the same construction,you con
submit one jnrm. 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
F'or multiple wells list all depths if'different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 23.5 (ft.) Division of Water Resources,Information Processing Unit,
U tinier 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 & 2" spoons construction
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 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
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