GW1-2021-05624_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells i
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I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 25 113 Wet
2973 ft. D.
NC Well Contractor Certification Number 15.OUTER CASING for mulwcased wells OR
FR O LNR
HES a licable
DIAMETER MAT ERIAL
Parratt-Wolff, Inc.
ft. I in.
Company Name 16.INNER CASING OR TUBING file6thermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 98 ft. 2 in. seh40 pve
List all applicable well pennies(i.e.Couniv,State, Variance,lr ieclion.etc.) ft. ft. in.
3.Well[ise(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 98 ft' 113 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEM ENT M ETHOD&AMOUNT
❑irrigation 0 1. 89 ft- Portland Cem Tremie
Non-Water Supply Well:
89 f`' 94 ft Bentonite Chil Tremie
❑Monitoring ❑Recovers
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
— FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
#1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage 94 113
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color%hardness,soilhrock type,grAn size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
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4.Date Well 7-18-21 MW-81 Ds)Completed: Well iD# ft ft ')'")�-.-�• ay..��`-' `>
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. I Uri it
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. "1:r<r,1,r,^.fit-'-') "•'i�,�
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
t� v
Physical Address.City;and Zip 21.REMARKS
Mecklenburg 8"Flush Cover
County Parcel identification No.(PiN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient)
35.411707 N -80.806545 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY.signing this./brat,1 herehv cerliw thai the❑eN(s)ivas(were)constructed in accordance
with 15A NC'AC 02C.0100 or 15A NCAC 02C.02f10 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No cow q/this record has been provided ui the well owner.
1(1his is a repair,Jill out known well construction in%rniation and explain the nature ql the
repair under.21 remarks section or on the back q1 this Jbrni. 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.
hor multiple injection or non-maier.supply hells ONLY irate the same construction,von can
subinil one form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 113 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
har multiple hells list all depths i/diJjerent(example-3 ,200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,information Processing Unit,
If water lerel 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
6 5/8 HSA&2"spoons&6"Air Hammer/4"PVC Casing 24a above, also submit a copy of ithis 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,i 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 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