GW1-2021-06248_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
I.Well Contractor Information:
i
Kevin White 14.WATER ZONES
'
FROM 1'O DESCRIPTION
Well Contractor Name 43 ft. 47 rt• Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING.for multi-cased wells OR LINER if a licable
FROM TO DI AM ETEH THICKNES5 MATERIAL
Parratt-Wolff, Inc. rt. ft.
in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 17 ft. 4 in. sch40 PVC
List all applic•ahle well permits(i.e.Coun(v,State,Variance,byeetion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE "THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 ft' 47 ft' 4 in. .010 sch40 PVC
r. f. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑industrial/Commercial []Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 fc• 13 ft. Portland Cem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
13 ft. 15 ft- Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
15 ft• 47❑Aquifer"test ❑ ft. #1 Sand TremieStormwater Drainage rt. ft.
❑Experimental-technology ❑Suhsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION uulur,bandness,suilhvck lytre, rain size,etc.
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-20-21 well ID# RW-54
ft. ft.
5a.Well Location: Pic
x'
Colonial Pipeline Company
Facility/Owner Name Facility IDN(if applicable)
rt. ft. �
14108 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip -
-21.REMARKS
Mecklenburg 4660199946/1921203
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lot/long is sufficient) � '
35.413228 N -80.806007 H
Signature ofCenitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hv signing this Jarm,l herehv certiJi,dial the wells)sous(were)constructed in accordance
wish 15A N'At•02C.0100 or 15A NCAC 02•.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy q/this record has been provided to the mell owner.
4 this is a repair,Jill out known well construction information and explain the nature a/tire
repair under 2/remarks section or an the hack of this fawn). 23.Site diagram or additional well details:
You may use the back of this page to'provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1-tor mularple byecdion or non-water supply wells ONLY with the sale construction,mtu c•ar
s•uhn it one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 47 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths lfc4ilerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 43 (ft.) Division of Water Resources,Information Processing Unit,
1/"water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA 24aabove, 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.I
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 days ofcompletionof'
13h.Disinfection type: Amount: well construction to the county health department of the count-where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013