GW1-2021-05626_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTIION
Well Contractor Name ft. ft.
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2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased
wells)
FROM TO w ellORR a cable
DIAMETER MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING eothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 2 R• 4 '"' SCh40 PVC
List all applicable hell permits(i.e.Couniv,Slate, Fortance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 f`' 32 f`' 4 '"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft. 8 ft- Portland Cem Tremie
Non-Water Supply Well:
8 ft 10 ft Bentonite Chi Tremie
oMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 10 ft' 32 rr, #1''Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,prain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 5-6-21 RW-64s)Completed: Well ID# ft. fr.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. O L.
14511 Huntersville-Concord Road, Huntersville, NC 28078
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)
35.415642 N -80.805700 W-
sig fore ofCeh7itied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this form,1 herehv certify that the nell(s)uas(here)constructed in accordance
hrith I.iA NCAC 02C.0100 or 1 SA NCA'02C.0200 Well Consiruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
4 this is a repair,fill out known well construction information and explain the nalure q(tlhe
repair under-.21 remarks section or on the hack o/7his 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 necessary.
1�or tuuhiple injection or non-neater supply urlls ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor muhiple a ells list all depths i1(1i11&renl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
It maler 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 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;Linderground 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 ofcomple[ionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. i
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Form GW-I North Carolina Department of Environmenl and Natural Resources-Division of Water Resources Revised August 2013