GW1-2021-06264_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 ft. ft.
6
2973 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I I in.
Company Name 16.INNER CASING OR TUBING eotbermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 11 ft. 4 in. sch40 pvc
List all applicable well permits(i.e.Uoun(v.Sraie, Variance,injection,etc.)
f[. ft. in.
I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'"'
❑Agricultural ❑Municipal/Public 11 ft' 66 rt' 4 .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 7 ft• Portland Gem-Tremie - --
Non-Water Supply Well:
OMonitoring ❑Recover_ 7 rL 9 rL Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK,ifapplicable)
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
9 ft• 66 f`' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage rt. I
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sbeets.if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sitil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 10-27-21 Well ID# RW-92 fr. ft. —t /
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable) II�F rr
ft. ft. !
14511 Huntersville-Concord Road, Huntersville, NC 28078 OR/1 I—
Anj
ft. ft. JJ( G UNl I
Physical Address,City,and Zip 21.REMARKS '
Mecklenburg No Cover
County Parcel Identification No.(PIN) ,I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: I
(if well field one rat/long is sufficient) s
35.416829 N 80.804134 W ti -
- Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Ili signing this form, I herebv ceriily dial the well(v)was(irere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy g1this record has been provided to the well o,ner.
If this is a repair,till oul kno vi well construction inlormation and explain the nature gjthe
repair under=21 remarkv section or on the back g/'this,form. 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.
For multiple injection or non-water supply welly ONL Y wiih the same construction,You call
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 66 24a. For All Wells: Submit this!form within 30 days of completion of well
1'br multiple wells list all depths ifdifferem(example-3 m200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
!hater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniecfron Wells ONLY: !,In addition to sending the form to the address in
6 5/8 HSA& 2" 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.anger,rotary,cable,direct push,etc.)
Division of Water Resources,ILlnderground 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 Department of Environment and Natural Resources—Division of Water Resources Revised August 2013