GW1-2021-06454_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used f'or single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
i
Well Contractor Name 40 ft. 70 ft. J Wet
2973 r'• r'•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER! '1'H ICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 35 ft. 2 in. sch40 PVC
List all applicable hell permits(i.e.County Stale,Variance,injection,etc.)
ft. ft. I in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLO'1'SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 R. 70 R- 2 in. .010 sch40 PVC
[]Geothermal(Heatin Coolin ) ❑Residential Water Su (single) ft. ft. in.
� g Supply) PPIY( )g
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 30 ft. Portland Cem Tremie
Non-Water Supply Well:
ZMonitoring ❑Recovery 30 r' 33 r' Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENTMETHOII
33 ° 70 f' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothernal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) e• ft.
4.Date Well 12-19-20 s)Completed: Well IDk MW-64
ft. ft. a
5a.Well Location:
Colonial Pipeline Company rt. fr.
ATWA
Facility/Owner Name Facility IDN(ifapplicable)14226 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. ` ',01ti1
ft.
Physical Address,City,and Zip
t
21.REMARKS ^ l t' "
Mecklenburg 4660296960/2104102 2 z 2 Pad
County Parcel Identification No.(PIN) 8"FMC
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
35.413329 N -80.804060 N; K
Signature of'Cenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary gY signing This/brit, I hereby c•erti[y ihatlihe we/l(s)rras(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC b2C.020U Well('unstrnc uun Stnndarels and that a
7.Is this a repair to an existing well: ❑1'es or I?INo copy q(this record has been provided to the well owner.
U'lhi.s is a repair,fill out known well construction inlnrnaaion and explain the nalure ofthe
repair under 21 remarks.section or an the hack of dtic jorni. 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.
I•br nndliple injection or non-waler supply wells ONLY with the saute construction,you can
submit one%brit. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nudtiple wells list all deputy ifilillereni(example-3 a 200'mrd 2@,100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Y water level is above casing,nse" 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" spoons24aabove, also submit a copy of this torn within 30 days of completion of well
12.Well construction method: construction to the tollowing:
(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
I
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:Also submit one copy of this form'within 30 daysofcompletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of'Environnnent and Natural Resources-Division of Water Resources Revised August 2013