GW1-2021-02725_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Wel I Contractor Name 38 R. 44.5 If Wet
2973 rt. e.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L1NER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 24.5 ft. 2 in. sch40 PVC
List till applicable well permits(i.e.Counl.Stale, Pariance,injection,etc.)
ft. f[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply NVell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24.5 It- 44.5 It- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 20 ft- Portland Cem Tremie
Non-Rater Supply Well:
OMonitoring ❑Recover' 20 ft 22 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 ❑Salinity Barrier 22 ft• 44.5 It' #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,girain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 3/5/21 MW-83 ft. ft.
$)Completed: Well ID#
ft. ft. Cr
5a.Well Location: ft. ft. p
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility IDk(ifapplicable)
ft. fL r rn SlU `{;�.;.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. e. trttor ,a�i ri -
Physical Address.City,and Zip r, Jv?I011
21.REMARKS
Mecklenburg 8"Flushmount
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
35.413250 N -80.808001 W ��, 7 .
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary HV signing this Dorm, I herehv certift that the wel/(s)was(here)constructed in accordance
with I.iA NCAC 02C.0100 or 15A NCAC 02C.020t1 Well Consirueifon Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the we/l owner.
Iflhis is a repair,fill out known well construction information and explain the nature o0he
repair wider.2I remarkv section or on the back at 11as 1brm. 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 necessan'.
For multiple injection or non-waler.supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 44.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depdis ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
4 water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: 'In addition to sending the form to the address in
10 5/8 HSA& 2" Spoons 24aabove, 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 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.
Form GW-I North Carolina Department of Envimnnietu and Natural Resources-Division of Water Resources Revised August 2013
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