GW1-2021-06437_Well Construction - GW1_20211022

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 48 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER 'THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name `16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 144 ft- 2 '"' sch40 PVC
/.ist all applicable+cell permits(i.e.C'omnv,Slate, Variance,Injection,eta)
ft. ft. in.
3.Well Ilse(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER 9LOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 144 ft' 154 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT'METHOD&AMOUNT
❑lrri ation 0 rt. 89 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Reaivery
89 ft- 115 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licabli
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
e• ft•
❑Aquifer Test ❑Stonmvater Drainage 115 154 #1 Sand Tremietr. 1t.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional,"sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tutor,hardness,soil/ruck type,gi.in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 3-8-21 MW-79Ds)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. rt. Q�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
13900 Huntersville-Concord Road, Huntersville, NC 28078 rt. rL 16is:rt Ccr1;0
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204
County Parcel Identification No.(PIN)
51h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.412524 N -80.807414
Signature of Certified Well Contractor Date
6.Is(are)the well(s): LaPermanent or ❑Temporary
Hy signing dlis/urnt, l hereby certiJi,lho(lhe+re//(+)was(+rere)runslruc&d in accordance
+rilh hA N'A'02C.010ll or,15A NCAC 02C.020(l Well('un.+'U•uclion SYandnrds and Ihut u
7.Is this a repair to an existing well: ❑Yes or ONo copy(Y'ihis record has been provided to the we//au ner.
//'this is a repair,fill oul known well construction information and explain the nature the
repair under=21 remarks.section or on the hack o/'thislarnt. 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 it'necessary.
hor nuthiple injection or non-Water supply tre//y ONLY with the saute construction,you call
suhnin one,/Ornl. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 154 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple wells list all depths i(Vi//erenl(example-3@200,and 2@100') construction to the following:
10.Static water level below top of casing: 104 (ft) Division of Water Resources,Information Processing Unit,
l/hater level is above 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
$rr casing and 4"Air Hammer 24a above, 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
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletionof
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013