GW1-2021-06442_Well Construction - GW1_20211022

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 ft. ft.
2973 ft. ft. t
NC Well Contractor Cenification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAD1ETERt 'THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING ifecothermal closed-loop)
FROM TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 31 ft. 4 in' SCh40 PVC
List all applicahle well permits(i.e.Coun(v,Slate.Variance,hyeeltnn,ec.)
in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 31 ft' 61 ft' 4 tn• .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
[Irrigation 0 rr• 26 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
26 1r• 28 rr• Bentonite Chii Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 28 fr• 61.5 ft• #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional iheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,-ilh ckt re, rain A.,etc.
❑Geothernal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
1-19-21 RW-50 rt. rt.
4,
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14108 Huntersville-Concord Road, Huntersville, NC 28078rc_,�'
rt. rt. et9�t (3vJF��w
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 4660199946/1921203
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
35.413296 N -80.805476 N,
Signature ofCenitied Wellrontractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing lhi.r,/arnt,/herehv c•ettiJy that ilie ire//(s)tray(were)constracled in accordance
With 15A NCAC 02C.0l110 or 15A NCAC 02C.0200 Well('unstnuctiun J'rundnrds and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy o/'this record has been provided to the well owner.
/l this is a repair,fill out knot ire//construction in/brnalion and explain the nature of lite
repair under;r 2l remarks section or on the hack q/7h/s/aril. 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.
bor iultiple injection or non-[rater supply wells ONLY frith the saute construction,You can
suhina one%nrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 61.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/4rr nwhiple tre//s list all depths t/dtllerenl(example-3@200'anti 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
/l irater level is above easing,use" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: Injaddition to sending the form to the address in
6 5/8 HSA with 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
i
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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.
Form 0 W-I North Carolina Department of Envirotnnent and Natural Resources-Division of Water Resources Revised August 2013