GW1-2021-06252_Well Construction - GW1_20211022

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 f'• 45 ff' 1 Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if n licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. rr. ft. in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loon)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 30 R• 2 in. sch40 PVC
list all applicable Iveli pernh.v(Le.Catuuv,,State, Variance,Mlection,etc-,) ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE '1'NICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft' 45 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMEN'l METHOD&AMOUNT
❑Irri ation 0 rr. 24 fc Portland:Cem Tremie
Nun-Water Supply Well:
0 Monimring ❑Recovers'
24 rt. 27 rr. Bentonite Chil Tremie
Injection Well: rt. fr.
i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL' EMI'LACEMENTMETHOD
ft ft
❑ 27 45 #1 Sand TremieAquifer Test ❑S[ormwater Drainage ft. ft.
❑lExperimental Technology ❑Suhsidence Control
20.'DRILLING LOG faintch additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,suilhvck type, -in size,etc.
❑Geothermal(Heating/Cooling Return) ❑ether(explain under#21 Remarks) ft. ft.
4.Date Well 12-21-20 s)Completed: Well ID# PMW-67 ft. ft.rt. tt.
5a.Well Location: ft. ft. ° Y
Colonial Pipeline Company
ft. ft.
ti-
Facility/Owner Name Facility IDk(if applicable) ft. ft.
14130 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS l t
Mecklenburg 4661202203/1921233
County Parcel Identification No.(PIN(
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if\yell field,one tat/lung is sufficient)
35.413269 N -80.804708 w; X,*',
Signature of Certified Well Contractor : Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
/ii'signing this./brat,l herehv e•eni/y that the trel/(v)uw.c(were)cunxauc•led it;uccurrlunee
with 15A NCAC ll2C.0/00 or 15A NCAC 02C.l1200 Well t'uns7rncliun,1Ynndurds and that a
7.Is this a repair to an existing well: 01'es or ZINo copy q/this record has been provided to the net/owner.
tj ihiv is a repair,fill out knolrn well construction in/brinalion and explain the nature alilte
repair touter-2/remarks section or on the back a/� .sihi jortu. � 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 ifnecessary.
For nnlople injection or non-maler supply wells ONLY Irish the sane canstrnctial,puu can
subnril one.lortn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 24a. For All Wells: Submit this form within 30 days of completion of well
hor nodliple u'el/.v list all depths i/diflereut(example-3@200'and 2 q/00') construction to the following:
10.Static water level below top of casing: 37 Division of Water Resources,Information Processing Unit,
I/hater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA & 2" SpOOnS 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,'Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletionof
13b.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