GW1-2021-06431_Well Construction - GW1_20211022

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 I'D DESCRIPTION
Well Contractor Name 59 ft. 70 Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we11s OR LINER if a licable
FROM TO DIAMETER THICKNESS 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 4: 0 ft• 55 ft. 2 in. sch40 pvc
l.itl all applicahle well permits(i.e.County,Agate,Variance,injection,etc.)
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM I'D DIAMETER 'SLOTSIZE THICKNESS M.ATERIAI.
❑Agricultural ❑Municipal/Public 55 ft. 70 rt• 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. EMPLACEMENTMETHOD&AMOUNT
❑h'ri ation 0 rr. 46 rt. Portland Cem Tremie
Non-Water Supply Well:
fJ Monitoring ❑Recovery
46 ft- 51 ft• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if ati licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAU EMPLACEMENTMETHOD
51 ft 70 ft #1 Sand Tremie
❑Aquifer Test ❑Stonnwa[er Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional Sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,­il/roi,k type,grain sire,utc.
❑Geothermal(Heating/Cooling Retum) ❑Other(ex lain under 421 Remarks)
fL fL
4.Date Well 5-10-21 s)Completed: Well ID# MW-31 D ft. ft.
5a.Well Location: ft. ft. ,gym a'i
Colonial Pipeline Company
Facility/Owner Name Facility IDN(ifapplicable)
ft. ft. E\
13900 Huntersville-Concord Road, Huntersville, NC 28078 rr. rt.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204 2 x 2 P Oro"..3 NR
County Parcel Identification No.(PIN)
8"Flush Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one tat/long is sufficient)
35.412004 N -80.807398 W � Wit --, :Z
Signature ol'Cenilied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing This form, I herelir cergh,Thal the well(.,) was(were)cunstr acted in accordance
with I5A NC'AC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy q/*a1us record has been prorided to the we/l owner.
ll'tti.v is a repair,till out known well construction inlhrinaoon and explain lire nature al'the
refx it under=21 remarks.section or all the hack of lhl.t/brie. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
I•itr mnlliple injection or anti-u•aler.supply wells ON1.Y with the saute construction,vuu can
snhinit one forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 24a. For All Wells: Submit this form within 30 days of completion of well
hior nudl/p/e wells list all deplhs i/di/Prent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 59 (ft.) Division of Water Resources,Information Processing Unit,
//hater level is ahore casing,ose" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: in addition to sending the tixm to the address in
6 5/8 HSA @ 2"spoons and 4"and 6"Air Hammer 24a above, also submit a copy of this torn within 30 days of completion of well
12.Well construction method: construction to the tollowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iluderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
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