GW1-2021-02731_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20 rt• 55 rc' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for -cased wells OR LINER if a ficable
FROM multi
TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft• 4 i" SCh40 pvC
list all apphc•able well permtr.s(i.e.Counh;State, Variance,injection,etc.)
ft. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 It- 55 fr• 4 i" .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
❑lrri ation 0 ft. rt. Portland Cem Tremie
Non-Water Supply Well: ft. ft.
[aMonitorine ❑Recovero Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer,Storage and Recovery ❑Salinity Barrier ft. ft. #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,gmin size,etc.
❑Geothermal(Heating/Cooliniz Retum) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 3-10-21 Well ID# RW-58
ft. ft. RF_Iut�'
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
m
Facility/Owner Name Facility ID#(if applicable)
ft. ft. e � ec� rat✓esSlnc�UI t
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. I: ��r, ,ores n
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 lat/long is sufficient)
35.415449 N -80.806465 W
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary B'v.Signing this.form, 1 herehv cernti,that the tre//(,l tras(were)constructed in accordance
,rich I SA NCAC 02C.0100 or I5A NCA('�02C.0200 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.
I/'this is a repair,fill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back o/'this%arm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-Crater supply wells ONLY with the same construction,,you can
submit one/brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 24a. For All Wells: Submit this form within 30 days of completion of well
Vor nmltiple wells list al/depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft•) Division of Water Resources,Information Processing Unit,
If 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 24a 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 of completion of
13b.Disinfection type: Amount: well construction to the county heallh department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013