GW1-2021-06251_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used f'or single or multiple wells
i
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 ft• 54 ff Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER 'THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eofhermal closed-loop)
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 34 ft. 12 i" SCh40 PVC
List all applicable well permits(i.e.Courgv,Stale, Variance,lnjec•tion,ele.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM I'D DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Puhlic 34 ft' 54 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I I'D MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft' 29 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
29 ft. 31 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEN'TMETHOD
❑Aquifer T 31 fL 54 ft- #1 Sand Tremieest ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Suhsidence Control
20.DRILLING LOG-attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/ruck type,grain size,e1c.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 12-23-20 Well ID# MW-66
ft. rt. � y��a
5a.Well Location: ft. ft.
Colonial Pipeline Company '
Facility/Owner Name Facility ID#(if applicable) ft. ft. O J 'r�J��1
14130 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. 'V?kU' W• J
r`Q�
Physical Address,City,and"Lip el n
21.REMARKS
'Oet" P
Mecklenburg 4661202203/1921233
County Parcel Identification No.fPIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.413549 N -80.804759 N I
Signature of Certified Well Contractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this./brit,/hereby c•erti&that the bell(,)eras (were)constructed in accordance
trial/SA N'AC 02C.0/00 or 15A NCAC 02C.0200 Well Consiruclion Standards and that a
7.Is this a repair to an existing well: 01'es or ElNo copy gf7his record hat been provided m the,well oovter.
l/this is a repair,till our known bell cOnsrruclion information and explain the nawre n17he
repair under-21 remarks section or on the hack a/'rhi.c/orm. 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 necessan.
hor multiple injection or non-water supply welds ONLY trial the same construction,Yon cot
submit one,Jorn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 54 (ft) 24a. For All Wells: Submit this farm within 30 days of completion of well
Par nintople bells lisl all depths ifthIleren(etaniple-3 a 200'nod 20( 100') construction t0 the following:
10.Static water level below top of casing: 37 (ft.) Division of Water Resources,Information Processing Unit,
//baler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 246. For Infection Wells ONLY: In.'addition to sending the form to the address in
8 1/4 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Igp ) 24c.For Water Supply&Injection Wells:
m 13a.field Method of test:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of'Water Resources Revised.August 2013