GW1-2021-06444_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells
1.Well Contractor Information: i
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Kevin White 14.WATER ZONES ;!
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. '
2973 ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAM ETERI THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I jin.
Company Name 16.INNER CASING OR TUBING(peother a]closed400
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 16 ft- 2 tin' SCh40 pVC
List all applicable well pernt0.r(i.e.Countyt State,Variance,hnleetion,etc-.)
ft. ft. 'in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I'D DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft' 46 ft. 2 in. .010 Sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOU&AMOUNT
❑Irri ation 0 et• 7 5 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recover)• 7.5 ft. 10 fr• Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENTNIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
10 46 #1 Sand Tremie
❑Aquifer Test ❑Storriwater Drainage tt. ft.
❑Experimental Technology ❑Suhsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION calur,hardness,sisith-Is(ypst,girstin size,ell'.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
3/14/21 MW-86
4.Date Well(s)Completed: Well[Div
mad'
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility IDN(ifapplicable) ft. ft. t•,rCr jlrtt�
14108 Huntersville-Concord Road, Huntersville, NC 28078 rt. rt. etas`' G�,df vc„1,
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg 4660199946/1921203
County Parcel Identification No.(PIN) 2 x2 pad and cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one[at/long is sufficient)
35.412011 N -80.805826
Signature of'Cenified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this.larm, 1 herebY c•erti/i,that the trell(+) war(were)constructed in accordance
with 15A NCAC 02C.t 100 or 15A NCAC l 2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy q/this record has been provided to the cell under.
/(this is a repair,,Jill out known well construction in,li naion and explain the nature of 1he
repair Hader a 2l remarks section or on the hack q/this.Jbrnn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
/•or nndtiple injection or non-water supply wells ONLY with the sane construction,you can
submit one forni SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 24a. For All Wells: Submit this form within 30 days of completion of well
/•br multiple wells list all depdts if diJJereni(example-3«200'and 20/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lJCraterlevel is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: fii addition to sending the form to the address in
10 5/8 HSA & 2" 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
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24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county heal i h department of the county where
constructed.
Form GW-I North Carolina Department of'Environment and Natural Resources-Division of Water Res ources Revised August 2013