GW1-2021-05620_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Imernal 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
fr. ft.
2973
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermalclosed-loo
FROM TO DIAMETER THIC"ESS MATERIAL
2.Well Construction Permit#: 0 ft' 12 ft. 4 '"' SCh40 pvc
List all applicable trell permits(i.e.Counw Slate.Variance,injection,etc•.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Nell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12 ft. 52 ft' 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 8 ft. Portland Cem Tremie
Non-Water Supply Well:
ry 8 fr. 10 ft- Bentonite Chi Tremie
OMonitoring ❑Recove
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S[ormwater Drainage 10 ft- 52 ft. #1 Sand Tremie
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neceisa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft• ft.
ft. it.
4.Date Wells Completed: 7-29-21 Well ID# RW-74
5a.Well Location: ft. ft. ii „`"'"
Colonial Pipeline Company ft. ft. 1
Facility/Owner Nance Facility IDif(ifapplicable) s
ft. ft. _ ry:..s c•;i'[t�i.9ilii
14511 Huntersville-Concord Road, Huntersville, NC 28078 Jr;s!,._;;�;;
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:
(ifwell field,one[at/long is sufficient)
35.415738 N, -80.805649 W +1,.,
Signature ofCcrtified Well Contractor - Date
6.is(are)the well(s): OPermanent or ❑Temporary H'v signing this form, /hereby certify that the ueN(s)was(here)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/'thi.s record has been provided to the a-ell owner.
!/this is a repair,fill out known well construction inlorntalion and explain the nature of the
repair tinder-21 remarks section or on the back g/'thi.s fornc 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.
l•or tnulliple injection or non-wafer supply wells ONLY with the same construction,,you can
submit one/hrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 52 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferew(example-3C200'anti 2@0100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifuwter level is above casing,use••- 1617 Mail Service Center,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& 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,11nderground 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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013