GW1-2021-06262_Well Construction - GW1_20211123

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 75 fr• 112 fr' ' Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 go ft. 2 in. sch40 pve
Lrst all applicable well permits(i.e.Couniv,State, Variance.Injection,etc.) fr. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 90 ft. 110 ft. 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 83 fr. Portland Cem Tremie -
Non-Water Supply Well:
FMonitoring ❑Recover 83 ft. 86 fr. Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT METHOD
FROM TO
86 fr• 112 tr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
Technology ❑Subsidence Control
20.DRILLING-LOGr(attach additionil sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft,
4.Date Well 11/9/21 MW-89 D ft. ft.$)Completed: Well ID# ft. NOV
ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft. DVHR SECTION
Facility/Owner Name Facility ID#(if applicable) ft. ft. MESSING UN!'
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
21.REMARKS i.
Mecklenburg 2 X 2 Pad&6"Cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/lone is sufficient)
i
35.414741 N -80.804364 W. k1. t . (0 . Z k
Sim re ofCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this form, I hereby cerit&that the well(s)was(were)constructed in accordance
with I5A NCAC 111C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy ofthis record has been provided to rite we/l owner.
If this is a repair,Jill out known well construction iglbrmation and explain the nature ofthe
repair under=21 remarks section or on the back gf1his form. 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.
Vor multiple injection or non-waler.supp/v wells ON/Y with the same construction,you can
submil ore farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 110 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
por nudliple wells list all depths ifdiJJerem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 75 (ft.) Division of Water Resources,Information Processing Unit,
If crater level is above casing use"-" 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
6 5/8 HSA/ &2"spoons/6"Air Hammer 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.)
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 torn
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 Department of Environment and Natural Resources-Division of Water Resources Revised August 2013