GW1-2021-06432_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: ll
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 39 ft. 48 fL Wet
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2973 f3. ft.
NC Well Contractor Certification Number 15.OUTERCASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETERI '1'H ICKNESS MATERIAI.
Parratt-Wolff, Inc. fr. ft. ifn.
Company Name 16.INNER CASING OR TUBING filcothermall closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rr. 33 ft. 2 in. sch40 pvc
List all applicable well permits(t.e.('aunty.Slate, Variance,hyec•tlon,etc-.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33 a' 48 ft- 2 in. .010 SCh40 pvc
f. ft. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I'D MATERIAL EMPLACEMENT METHOD&AMOHNT
❑Irri ation 0 ft' 28 ft, Portland Cem Tremie
Non-Water Supply Well:
17IMonitoring ❑Recovery
28 ft. 31 fr. 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 EMPLACEMENT METHOD
ft ft
❑Aquifer"test ❑ 31 48 #1 Sand Tremie
Slormwater Drainage ft. ft.
❑ENperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additlonal'Aheets if necessaR4 An
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(cptti r n sus t te, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft. ��
`L ft. �
4.Date Well(s)Ctnnpleted: 12-20-20 Well ID# MW-70 tt. ft. o �tl111
5a.Well Location: ft. ft. Y; fi4�' vD
Colonial Pipeline Company rt. fr.
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Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14226 Huntersville-Concord Road, Huntersville, NC 28078 ft. rt.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 4660296960/2104102 8°FMC
County Parcel Identification No.(PIN) 2 x2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
35.413302 N -80.804380 N, 4-kit"_
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): IZIPermanent or ❑Temporary y signing I I (1 ( )
H this ornl, 1 hereby c•ern v lhn/,die molls was were cansnvcted in accordance
With 15A NCAC 02C.0100 or 15A NCA!•02C.0200 Well Consiruclion Standards and Thal a
7.Is this a repair to an existing well: ❑Yes or EINo copy gf1his record has been provided to the well owner.
lit this is a repair,fill out known Well construction inJnrmalion and explain the nature of 1he
repair larder-21 remarks section or on the hack of'this,lorm. 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.
PLr nmlliple injection or non-waler supp/Y wells ONLY with the sane construction,You can
submit one./brnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 48 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Ptir nndliple wells list all depths t/'di(/ereni(example-3 a,200'and 2@100') construction to the following:
10.Static water level below top of casing: 39 (ft.) Division of Water Resources,Information Processing Unit,
if water level is ahor•e casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
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" 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,[1Llderground 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 of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. 1
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Fornt GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013