GW1-2021-02728_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
Well Contractor Name 30 ff 366 ff Wet
2973 rt. 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. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 16 ft- 2 in. SCh40 PVC
List all applicable well permits(i.e.(brunt',State, Variance,lniection,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 16 ft' 36 ft. 2 in. 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 12 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitorina ❑Recovery 12 fl• 14 ft Bentonite Chil Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a' Iicatile
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft
El Aquifer Test ❑Stormwa[er Drainage 14 ft• 36 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control ,
20.DRILLING LOG(attach additions,l sheets if necessa' ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,scil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
`t' ft.
Date Well 3/9/21 MW-85 s)Completed: Well ID# R°., „e M :L
•—j
d e
5a.Well Location: e. ft. I
Colonial Pipeline Company ft. ft. 021
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. li i.^tfi'. iOH i rIjt,r1.s
A ^YI
Physical Address,City,and Zip 21.REMARKS WQ °v
Mecklenburg 8"Flushmount
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 Iat/long is sufficient)
35.413253 N -80.807913 w ��
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this/brm, I herety cergty that the well(s)was(were)constructed in accordance
with 15A NCA'02C.0100 or I.iA NCAC'02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to ih'e well owner
l/this is a repair,fill out known well construction imbrnration and explain the nature of the
repair under 21 remarks section or on the back q/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 meduple inieclion or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1;or multiple wells list all depths it different(example-3 n 00'and 1 tr 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
l/ivoter level is above casing,use - " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
10 5/8 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,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 forth 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 Water Resources Revised August 201_'+
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