GW1-2021-06545_Well Construction - GW1_20211022

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 ORLiYER ifa 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16,INNER CASING OR TUBING(geothermal dosed-loo
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 20 ft. 4 i"• SCh40 I PVC
List all applicable irell permits(i.e.r•nunitt State, Variance,Injection,etc'.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 "" 40 ft. 4 i" ; .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. ft. in.
(sin le) '
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 15 f° Portland Cem Tremie
Non-Rater Supply Well:
Z Monitoring ❑Recoven
15 ft. 17 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa Iicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 rr. 39 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage 1t. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colon hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 8-26-21 Well ID# RW-80
ft. ft- fn t\
5a.Well Location: ft. ft. t_'\ ,,ia'
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility IDk(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
Physical Address,City,and Zip .,^.`3ss''' Ca6,Q 1
21.REMARKS [i t1� p1)' T`"
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one fat/long is sufficient)
35.413810 N -80.806725 W 0
G 9
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv signing This Jbrnn, l herehv c•erif/i•dna the we//(s)was(were)consvrucied in accordance
Frith 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and than a
7.Is this a repair to an existing well: ❑Yes or E]No copy o(ihis record has been provided to the well owner.
U this is a repair,fill oul known well consmuction inlbrmation and explain the nature of the
repair Bander=21 remarks section or on the back gjihis 1brm. 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.
Ivor muhip/e injection or non-waier.supply wells ONLY wilh the same construction,you can
subnui one./orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•br mnhiple wells list all depths it diljerenl(example-3r<100'and 1@100') construction t0 the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
1/waler 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
6 5/8 HSA& 2" spoons construction
above, 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 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 daysofcompleuonof
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