GW1-2021-06433_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD For Iinental Use ONLY:
This farm can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 rr 33 rr' Wet
2973 a• ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for mull'-cased wells OR LINER if a licable
FROM TO DIAMETER' "THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. t't. in.
Company Name 16.INNER CASING OR TUBING ifecothermall closed-loop)
FROM TO DIAMETER "THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 18 ft- 2 in. seh40 PVC
List all applicahle well pernils(i.e.CounfY,Stale, Variance,hyeelion,eu.)
ft. ft. fin.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 "' 33 ft. 2 in. ' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOLINT
❑hri ation 0 ft. 13.5 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
13.5 ft- 15.5 fr• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Crroundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑ 15.5 ft' 33 ft- #1 Sand TremieStormwater Drainage fr. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hacduess,soil/rock type, Cain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft,
2/8/21 MW-74 ft. ft. .,� "��
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Colonial Pipeline Company rt. e. t1tzl
ssit�g
Facility/Owner Name Facility ID#(if applicable)
14226 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660296960/2104102 8"FMC
County Parcel Identification No.(PIN) 2 IX2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lal/long is sufficient)
35.414272 N -80.8804149 N,
Signature ot'Certitied Well Contractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary f I1' (J (were)Hv signingthis orni,/lrerehy c•ervi ihui the ire//.c was were cunsu•ueied in accurdunee
Irish 15A NCAC Il2C.0100 or 15A NCAC WC.0N/0 Well Cunslrucliun Slumlords and Ihul a
7.Is this a repair to an existing well: ❑Yes or EINu copy of dii.s record has been provided io die well owner.
Y'his is a repair,fill ow known well construction infbrnialion and explain the nature of the
repair under:21 remarks section or on the hack q/.ihi.v farm. 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.
Par multiple injection or non-baler supph•we//s ONLY frith the same construction,you can
suhniil one,/nrni, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 33 (ft.) 24a. For All Wells: Submit this torm within 30 days of completion of'well
P'or multiple hells list al/depths it different(extin)ple-.?ct,200'amd 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
//'crater level is above caving,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" split 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.) 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 daysofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department ol'Enviiomuent and Natural Resources-Division of Water Resources Revised August 2013