GW1-2021-06435_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple Hells
I.Well Contractor Information: t
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 25 ft• 45 ft. Wet
2973
NC Well Contractor Certification Number I5.OUTER CASING(for multi-cased welts)OR LINER if a licable
FROM TO DIAIIIETER. THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 115 ft. 2 in. sch40 PVC
List all applicable well pernii.s(i.e.Counw,Siate,Vartanc•e,Injection,etc•.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply NYell: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 45 ff 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 10 ft. Portland Cem Tremie
Non-Water Supply Well:
10 ft• 13 It- Bentonite Chil Tremie
hJ Mon itori ng ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PAC K'(if a licable .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft• ft•
❑Aquifer Test ❑Stormwater Drainage 13 45 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑•tracer FROM TO DFSCRIPTION culm,hardness,suil/ruck[ a hxin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 2/24/21 MW-77s)Completed: Well ID#
0. fr. fl
5a.Well Location: ft. ft.
Colonial Pipeline CompanyTi?
- 0rvr3- t•IOTt
Facility/Owner Name Facility ID#(if applicable) ft. fr.
UVV IN
13900 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204 4"Stick up cover
County Parcel Identification No.(PIN) 2 X2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one pat/long is sutlicient)
35.412725 N -80.807561 W - ( , 01 (
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cerit/p that the well(,)was(were)constructed in oc•cordante
with 15A NCAC 02C.t1100 or 15A NCAC 02C.0200 Well Construc tiara Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of1his record has been provided to the wel/au ner.
//'this is a repair,(ill out known well construction in/urination and explain the nature o/the
repair under=21 remarks section or oil the back q/'this/nrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor nuthiple injection or non-Crater supply wells ONLY with the scone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this form within 30 duvs of completion of well
hor multiple we/ls list all depths i.fei1jereni(exanhple-3 a 200'and 20100') construction to the following:
10.Static water level below top of casing: 25 (ft-) Division of Water Resources,Information Processing Unit,
I/'water level is above casing,use" - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the fium 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLI': 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 ofcompletion of'
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I Not Carolina Department of'Environment and Natural Resources-Division of Water Resources Revised August 2013