GW1-2021-03825_Well Construction - GW1_20210823

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
ft. ft.
2973 ft. ft.
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. tt. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loolall
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 22.5 ft 2 i" SCh40 I PVC
List all applicable,cell permits(i.e.('aunty.State.1,orianc•e.Injection,etc.)
ft. fr. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22.5 fr' 37.5 fit- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 18 ft- Portland Cem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
18 ft. 20 fr. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
and Tremie
❑Aquifer Test ❑ 20 ft' 37.5 1" #1 S
Stormwater Drainage ft. fr.
❑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/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 12-21-20 Well ID# PV-09
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. fr. `�`, I
Physical Address.City,and Zip
21.REMARKS
Mecklenburg No co,fir
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if\yell field.one lat/lonnz is sufficient)
35.412962 N -80.805140 W.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary BI,signing this 1brm, /herebv certify that the,re//(s)was(,Pere)constructed in accordance
with 15A NCAC 02C.0100 or 15A N(',4t'02C.0200 IVOI Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gfthis record has been provided to the we//owner.
1/'this is a repair,Jill out known well construction information and explain the nature of the
repair under-21 remarks section or mt the back g/'this 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 necessan.
Fier multiple ittiection or non-,rater supply nwellx ONLY,rith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or neduple,welily list all depths ifdifferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
t irater 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" spoons24aabove, 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 flail 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 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
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