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
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❑ 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.
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resoulrees Revised August 2013
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