GW1-2021-02732_Well Construction - GW1_20210514

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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 20 f`' 50.5 f`' l Wet
2973 ft. ft.
NC Well Connector Certification Number 15.OUTER CASING for multi-cased:wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 110.5 ft• 14 in. sch40 pvc
List all applicable nrll pernias(i.e.Couniv,State,Variance,It iection,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 10.5 f`' 50.5 f`' 4 '"' .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
6 f` 8 f` Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier a f`' 50.0 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
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4.Date Well 3-10-21 RW-59 ED
s)Completed: Well ID# ft. ft. REGIE
5a.Well Location: ft. ft.
I'l AY Colonial Pipeline Company ft. ft.
021
Facility/Owner Name Facility to#(ifapplicable) In forma a . n PrC sing Unl
14511 Huntersville-Concord Road, Huntersville, NC 28078 e e n
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No cover
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)
35.415421 N -80.806427 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary gy signing this fbrm, I hereby c•ertif,that the n ell(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Fes or ONo cony of this record has been provided to the me//oumer.
fJ this is a repair,fill out known well construction information and explain the nature of7he
repair under=21 rentarks.section or on the back ofthis 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 multiple injection or non-maler supply ire/ls ONLY frith the same construction,you can
submit one/arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor muhiple mel/s list all depths ifdi#Lreni(example-3@200'and 2 a 100) construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
1J trater level is above casing,use" 1617 Mail Service Cen i ter,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 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(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 health department of the county where
constructed.
Form GW-I North Carolina Department ot'Environment and Natural Resources-Division of Water Resources Revised August 2013
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