GW1-2021-06449_Well Construction - GW1_20211022

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name 38 f'• 44.5 f'' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL.
Parratt-Wolff, Inc. ft. ft. lin.
Company Name .16.INNER CASING OR TUBING. eofhermal closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 24.5 f'' 2 i" SCh40 PVC
List all applicable ire//pernttts(i.e.County,,Slate, Variance,injection,ele.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24.5 f'' 44.5 R. 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. I f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt• 20 r'• PortlandlCem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
20 f' 22 f'• Bentonite'Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENTMETHOD
f' f'
❑Aquifer Test ❑Stormwater Drainage 22 44.5 #1 Sand Tremieft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG jittach additionallsheets if necessary)
❑Geothennal(Closed Loop) []Tracer FROM TO DESCRIPTION wlur,hardness,-ith-Iti e,grain size,ul.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. R.
4.Date Well(s)Completed: 3/5/21 Well ID# MW-83 ft. ft.
ft. ft. Tt"�
5a.Well Location:
Colonial Pipeline Company e. -
Facility/Owner Nanic Facility IDk(if applicable) ft. ft. r t117
13900 Huntersville-Concord Road, Huntersville, NC 28078 c ey''1g
a,
rt. I
;VIR 54-'C,1l0f1
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:
(if'well field,one[at/long is sufficient)
35.413250 N -80.808001 N, ,�k (S,
Signature ofCenitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary X /. �. O (were)By signing this nrn+,l hereby c•ern y that the wells was here e'unslrucled in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well<'ons7ruc•Oun JYandurds and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy of ihi.s record has been provided to the ire//oirner.
l/Ihis is a repair,,Jill out known we//c•onstruclion it fornialion and explain the nature allhe
repair under a21 remarks welion or on the back of'ihi.s orni. 23.Site diagram or additional well details:
You may use the back of this page to provide additiunal well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
har nndliple injection or non-water supply ire/k ONLY with ihe.eante construction.you can
submit oneJorni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 44.5 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
/•or ondople wells lisl all depths i/'di/jerent(example-3@2011'cord 2(tD/00') construction to[Ire following:
10.Static water level below top of casing: 38 (ft•) Division of Water Resources,Infurmation Processing Unit,
lfu•aler level is above caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: It addition to sending the form to the address in
10 5/8 HSA& 2" SpOOnS 24a above, 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.) i
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 form within 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 Deparinient of Environnieni and Natural Resources-Division of Water Reslources Revised August 2013