GW1-2021-03823_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple%veils
I.Well Contractor Information:
14.WATER ZONES
Kevin White FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 22 ft. 2 in' I SCh40 PVC
List all applicable well permits(i.e.Comrty,State, Variance.Injection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22 ft 37 ft- 2 in. .010 SCh40 pVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) fr. 1t. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 rt• 16 rt• Portland Cem Tremie
Non-Water Supply Well:
0 Mon itoring ❑Recoven
16 ft. 18 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 ft•
❑Aquifer Test ❑ fr. 37 #1 Sand Tremie
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/-k type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) ft. ft.
4.Date Well 12-15-20 PV-09 ft. ft.
$)Completed: Well iD# ft. ft.
5a.Well Location: ft. fr.
Colonial Pipeline Company
Facility/O,vner Name Facility iD4(ifapplicable) ft. ft. 2�
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
't
Physical Address.City,and Zip Utl
21.REMARKS
Mecklenburg No coverl%31l'"'
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one[at/long is sufficient)
35.412954 N -80.805325 w
Signature of Certih 'ell Contractor Date
6.is(are)the well(s): [OPermanent or ❑Temporary
/3v signing this form, 1 herehi certify that the u•ell(s)was(irereJ constructed in accordance
uvth 1 SA NCAC 02C.0100 or 1 JA NC'AC 01C.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copv of this record has been provided to the,veil owner.
11 this is a repair,fill out known well construction information and explain the nature of the
repair under 11 remarks section or on the back q/ihis/brill. 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.
/•or multiple injection or non-water supply wells ONLY with the same construction._von can
submit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l-or nultiple wells list a/1 depilxs if thIlerent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
//grater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For infection Wells ONLY: 'in addition to sending the form to the address in
8 1/4 HSA and 2" S 24aabove. also submit a copy of this form within 30 days of completion of well
OOfiS
12.Well construction method: p construction to the tollowing:
(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 clays ofcompletion 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