GW1-2021-03824_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for sinale or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Kevin White FROM TO DESCRIPTIONI
ft. ft.
Well Contractor Name
2973 ft. ft. � �
15.OUTER CASING for multi-cased wells OR LIVER if a ILcable 1
NC Well Contractor Certification Number FROM TO DIAMETER THICIINFSS MATERIAL
Parratt-Wolff, Inc. ft. ft
16.INNER CASING OR TUBING(geothermal closed-log
Company Name FROM TO DIAMETER THICAI MATERIAL
2.Well Construction Permit#: 0 f" 22 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.('ounrv.Scale,I%ariance,Injection,etc•.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIGNFSS MATERIAL
Water Supply Well: 22 tt. 37 ft.
❑Agricultural ❑Municipal/Public 2 ' 010 sch40 PVC
ft. ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 16 rr• Portland Cem Tremie
Non-Water Supply Well: 16 rt. 19 rr• Bentonite Chil Tremie
ZMonitoring ❑Recoven
ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL. I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 19 f` 37 it' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soiUmck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
12-20-20 PV-10 `L
4.Date Well(s)Completed: Well ID# ft ft.
5a.Well Location: ft. ft. .F
Colonial Pipeline Company ft. ft. , �,` 'a wm
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. A
t^ .
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No cove{r,�c�� r� ec�ion
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)
35.412952 N -80.804931 W.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary yv signing this fornc, 1 hereby certify that the we//(s) was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA IvCk 02C.0200 Well Conscruclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
//'this is a repair,Jill out known well construction information and explain the nature of the
repair under -21 remarks section or on the back of dus Jorm. Y 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-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one Jornc.
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells. Submit this form within 30 days of completion of well
bor multiple wells list all depths it different(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
Owater 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" SpOOnS 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,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Alethod of test: 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.
i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 201?
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