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HomeMy WebLinkAboutGW1-2021-06446_Well Construction - GW1_20211022 i WELL CONSTRUCTION RECORD For Internal Use ONLY: This farm can be used for single or multiple wells 1.Well Contractor Information: Kevin White14.WATERZONES FROM TO DESCRIPTION': Well Contractor Name ft. ft. 2973 ft. ft. NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable FROM TO DIAM ETERI "fH ICKNESS MATERIAL Parratt-Wolff, Inc. Company Namc 16.INNER CASING OR TUBING eothermal closed-loop) FROM TO I DIAMETER I THICKNESS MATERIAL 2.Well Construction Permit#: 0 ft' 30 ft. 12 in• SCh40 PVC List all applicable well permits(i.e.('aunty,State,Variance,Injection,etc) ft. ft. !in• 3.Well lase(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public 30 r`' 45 ft. 2 in. .010 sch40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft fL in, ❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT FROM TO MATERIAL; EMPLACEMENT111ETHOD&AMOUNT ❑Irri ation 0 fr• 25 It. Portland Cem Tremie Non-Water Supply Well: Monitoring ❑Recover} 25 ft. 27 ft. Bentonite Chil Tremie Injection Well: ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if a licable ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD r` rt• ❑ 27 45 #1 Sand TremieAquifer Test ❑Stormwater Drainage rt. tt. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary) []Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(culur,hardness,suil/ruck type, rain size,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 4.Date Well 1/10/21 MW-73s)Completed: Well ID# ft, ft. 5a.Well Location: ft. ft. O 2 Colonial Pipeline Company Facility/Owner Namc Facility ID#(if applicable) t s✓�"' , 14108 Huntersville-Concord Road, Huntersville, NC 28078 Physical Address,City,and Zip 21.REMARKS Mecklenburg 46601999946/1921203 County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (if'well field,one lal/long is sufficient) 35.412179 N -80.805693 N; ` a, Signature ofCcrtified Well Contractor Date 6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing This limn, I herehY ceriify that the well(t)it us(mere)constructed in accordance with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well('oustractiun SYandurds and that a 7.Is this a repair to an existing well: ❑Yes or ONo copy nllhis record has been provided to the%tell owner. /(this is a repair,fill out known well construction inlnrination and explain the nature o.0 he repair under 42I rentarks section or on the hack o/'thir Juan. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary. hor nndarple injec lion or non-water supply wells ONLY with the same construction,You can submit one.lorhn. 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 /•or nwhiple wells list all depths i1 dt(lereni(exmnple-3@200'and 2(a,/all') construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, //rater level is ahore easing,use" 1617 Mail Service Center,!Raleigh,NC 27699-1617 11.Borehole diameter: 2 (in.) 24b. For Iniectiion Wells ONLY: In iaddition 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 13a.Yield m Method of test: 24c.For Water Supply&Injection Wells: (gP ) Also submit one copy of this form within 30 days ofconnpletionof 13b.Disinfection type: Amount: well construction to the county health department of the county where constructed. I Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resoulrees Revised August 2013 r