GW1-2021-06436_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:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 35 f`• 45 f`' r Wet
2973 ft• ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mWrl-cased wells OR LINER if a licable
FROM TO DIAMETER, 9'HICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.1NNER CASING OR TUBING geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 25 ft- 2 in. seh40 pve
List all applic•ahle irell pennies(i.e.ComUtl Slale,Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply NVell: FROM TO DIAMETER SLOTSIZE "THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 ft. 50 ft. 2 in. .010 sch40 pvc
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROAT
FROM TO MATERIAL EMPLACEMENT MLITIOD&AMOUNT
❑irri ation 0 13. 20 fl• Portland Cem Tremie
Non-Water Supply Well:
MMonitoring ❑Recovery 20 f` 23 f` Bentonite Chil Tremie
Injection Nell:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a" licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
23 ft- 50 ft. #1 Sand Tremie
❑Aquifer"test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach'additional'sheets if necrssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suil/i ock type,giain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
rt. rt.
4.Date Well 2/25/21 s)Completed: Well ID# MW-78
ft. ft. ;� ;�
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
13900 Huntersville-Concord Road, Huntersville, NC 28078 01111
ft. ft.
Physical Address,City,and Zip r �,s ullOfl
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:
(itwell field,one tat/long is sufficient)
35.412904 N -80.807584 N,
Signature ofCertitied Well Contractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hp signing ibis%rn, l herehv c•eni&that the ire//(s) u•ur(trere)constructed in accordance
11101i I5A NCAC 02C.Mettle or 15A NCAC Il2C.t1200 Well Construction Siondards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been prorided to the u•e//tmrner.
ll'thi.s is a repair,,Jill alit known ire!/construction in/nrnaltnn and explain the nature of the
relwir under=21 rentarks section or an the hack q/this,Jnrnl. 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.
I,irr multiple injection or nun-Crater supper wells ON1.Y irith the same construction,You call
suhnit one,Jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mulliple wells list al/depths iJ dilkretil(example-J@D200,and 2@1/ell') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
!J'traler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection iWells:Also submit one copy of this form, within 30 days ofcomplelionof
13h.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