GW1-2021-06445_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD I'm Internal Use ONLY:
This form can be used rot single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION,
Well Contractor Name 35 rt• 45 rf wet
2973 ft. ft. IE
NC Well Contractor Certification Number 15.OUTER CASING for mu1H-cased wells OR LINER if a licable
FROM TO WIMETERI THICKNESS MATERIAI-
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 25 ft. 2 in. SCh40 pVC
List all applicable well permits(i.e.Coun!v,State,Variance,Injection,etc-.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 9'D DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 f" 45 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. rt. in.
❑Ind ustrial/Commercial []Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 rr. 21 ft- Portland;Cem Tremie
Non-Water Supply Well:
[?]Monitoring ❑Recovery 21 ft. 23 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM I TO I MATERIAL EMPLACEMENT METHOD
ft rr #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage 23 45
ft. ft. I
❑Experimental'rechnology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hardness,suil/rucktype,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
rt. rt.
4.Date Well 2/10/21 MW-76 s)Completed: Well ID# a
5a.Well Location: ft. R. 1
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID4(ifapplicable) r,r .,r t:J
14108 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660199946/1921203 4"Stick up cover
County Parcel Identification No.(PIN) 2'ix2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.414299 N —80.804067 W
Signature of•Cenified Well Contractor Date
6.Is(are)the well(s): 01permanent or ❑Temporary BY.signing this Jorm, I hereby cerisli,tha yhe trell(,)trus(were)constructed in accordance
Irish 15A NCAC 02U.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/'doss record has been prorided to the Ire//owner.
I/this is a repair,fill out known trell construction information and explain the nantre fifthe
repair Lander r2l rewarks.section or on the back n/'ihi.r form. 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.
l,ar i n ltiple injection or non-water.supply wells ONLY wish the same construction,puu can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
(ar multiple ere//.s list all depslis i/ds/jereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing[]Hit,
If water lerel is abore caving,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
8 1/4 HSA & 2" split spoons 24aabove. also submit a copy of this turn within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 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 formiwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of&rvironmem and Natural Resources—Division of Water Resources Revised August 2013