GW1-2021-06447_Well Construction - GW1_20211022

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name 30 ft 366 ft' I Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased wells OR LINER ifa livable
FROM TO DIAMETER. 'THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 16 ft. 2 in. sch40 PVC
List all applicable well permas(i.e.Coaniv.State,Variance,lnleclion,ele.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft' 36 ft. 2 '°' .010 sch40 PVC
ft. f. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. fr.
12 Portland;Cem Tremie
Non-Water Supply Well:
MMoni[oring ❑Recover)
12 ft 14 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 TO I MATERIAL EMPLACEMENTMETHOD
14 ft- 36 ft- #1 Sand Tremie
❑Aquifer Test ❑SHlmnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suilh-It type, rein size,el,.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tt. ft.
MW-85
4.Date Well(s)Corn Com 3/9/21 pleted: Well ID#
5a.Well location: ft. fr. tl
Colonial Pipeline Company rt. rt. �SYlIL
Facility/Owner Name Facility ID#(if applicable) ..
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg 4660193695/1921204 8"Flushmount
County Parcel Identification No.(PIN) 2;x2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.413253 N -80.807913 N,
Signature ofCeilitied Well Contractor Date
6.Is(are)the well(s): CaPermanent or ❑Temporary By signing Ihi.s.lorni, l herehv cerit&tuldhe well(s)was(were)constructed in accordance
frith 15A NCAC 02C.0l00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 01'es or ONo eopv of this record has been provided to the!well owner.
lfthi.s is a repair,fill out known hell construction inlnrntation and explain the nature oflhe
repair under all rentarkr.section or an the back of iM.s/brit. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor uulliple injection or non-waler.sapp(y wells ONLY with the same construction,You can
snbntit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fbr multiple we1Ls list all depths ifdifferaa(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
l/water lerel is abore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: in addition to sending the form to the address in
10 5/8 HSA& 2" spoons24aabove, also submit a copy of this tone 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
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this forml within 30 days ofcompletionof
13h.Disinfection type: Amount: well construction to the county health:department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013