GW1-2021-02729_Well Construction - GW1_20210514

6
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
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
0 fL 40 ft• 2 "'' SCh40 PVC
List all applicable well permits(i.e.Counrn,State, Parlance,litjec•tion,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 40 f" 69 ft- 2 '°' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 33 ft. Portland Cem Tremie
Non-Water Supply Well:
33 ft. 35 f`' Bentonite Chil Tremie
EMonitorina ❑Recovery
Injection Well: fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO
35 f` 69 ft. MATERIAL EMPLACEMENT METHOD
#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,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
2-6-21 HCW-24 ft. ft. ;Io
4.Date Well(s)Completed: Well ID# rt. fr.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. JvJ JA I1
Facility/Owner Name Facility lD4(ifapplicable) ft. ft
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if•well field.one lot/long is sufficient)
35.413893 N -80.804266 W. �A)
Sin re of Certified Well Contractor Date
6.Is(are)the well(s): [aPermanent or ❑Temporary By signing sins fiirni, d herehv ceriifv that the we//(s)it (were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standards and chat a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the ve/l corner.
(f ihis is a repair,fittl out known well construction inJarmalion and explain the nanire oj'lhe
repair under-.21 remarks section or on the back q1 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.
hor innhiple injection or non-trater.supply wells ON1.Y with the,same ennstruction,you can
submit one forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 69 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hiir multiple wells list all depths tfdtfferent(example-9@200'and 2 n l00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/flrater/ere/is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (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
24c.For Water Supply&likiection Wells:
13a.field(gpm) Method of test:
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 ot'Environnient and Natural Resources-Division of Water Resources Revised August 2013
f