GW1-2021-02735_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
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Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. fr.
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. I in.
Compam Name .16.INNER CASING OR TUBING fileothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 4 in. sch40 pvc
List all applicable well pernntis(i.e.Coutnty,Slate, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 fL 55 ft. 4 in' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 6 fL Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recover_`
6 rr. 8 fL Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHOD
Salinity Barrier I
❑Aquifer Test ❑Stormwater Drainage 8 f`• 55 ff• #1 ,Sand Tremie
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 sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 3-16-21 RW-62s)Completed: Well ID# ft. ft.
Q
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. v
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. n-r sSing Unit
Physical Address,City,and Zip r . t' -1}1 cie-.'t
21.REMARKS P oiY
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one[at/long is sufficient) \
35.415579 N -80.806366 W
Signature ofCertr ontractor NJ Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this./firm, I hereby certift that the well(s)u,as(ucere)constructed in accordance
❑ah I SA NC'AC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Slandordv and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy q/this record has been prortded to the ire//owner.
4 this is a repair,fill out known wet/construction informalion and explain the nature q/the
repair under-21 remarks section or on the back q/'this 1brnn. 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 nutlliple injection or non-iraler.supply yells ON/Y u nh the same construction,You can
submil oneltbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
/br multiple ire/Is list all depths/f*dijferenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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 Iniection 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 m Method of test: 24c,For Water Supply&Injection Wells:
(gP ) 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 of Environment and Natural Resources-Division of Water Resources Revised August 2013
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