GW1-2021-02721_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 ft. ft.
2973 ft. ft.
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(geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construcfion Permit#: 0 ft' 17 ft. 2 '"' SCh40 pvc
List all applicable well permits(i.e.C'ouniv,State.14ariance.injection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 ft. 37 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling ) ❑Residential Water Su (single) R. ft. in.
Supply) PPIY( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 rt. 12 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 12 ft 18 ft• Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
18 ft 37 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if,necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
f`' f
4.Date Well 3/3/21 MW-81s)Completed: Well ID# � 6 '
5a.Well Location: ft. ft. E
Colonial Pipeline Company
Facility/Owner Name Facility ID4(if applicable) f[. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. Information Processing U(n:
Physical Address,City,and Zip y �t
21.REMARKS
Mecklenburg 8"Flush Cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.411672 N -80.806653 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary 13v,signing this/brit,1 herekv certift that the wells)was(were)constructed in accordance
With 15A NC'AC 02C.010C1 or 15A NC'AC 02C.0200 Well C'on.struction Standards and that a
7.Is this a repair to an existing well: 01'es or ONo copy of this record has been provided to the we//owner.
If is a repair,fill out known well construction information and erplain the nature of the
repair under=11 remarks section or on the back of flus Jorm. 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.
hor multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one farm. 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
('or mtdtiple wells list a/I depths tjdi(/erent(example-3@200'and 2 a 100') construction t0 the following:
10.Static water level below top of casing: (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: I In addition to sending the form to the address in
8 1/4 HSA & 2" spoons24aabove. 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,hnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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. I
Form GW-I Notch Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013