GW1-2021-07196_Well Construction - GW1_20211006

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.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
FROM TO DIA\PETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING-OR.TUBING.'(geothermal closed-loop
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 ft. 4 in. SCh40 pvC
Lieu all applicable well permits(i.e.County,Niate,Variance,Infection,etc'.)
ft. f[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 60 f`' 4 t"" .010 sch40 pvC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. i�•
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT El Irrigation 0 ft. 11 ft- Portland Cem Tremie
Non-Water Supply Well:
11 f` 13 f` Benton'ite Chil Tremie
EMonitoring ❑Recover
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 f`• 60 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sim,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 7-23-21 RW-71 ft. ft.$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. 6
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft. 10 PCi�\d�
Physical Address,City,and Zip
21.REMARKS,;,
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one hit/long is sufficient)
34.415741 N -80.805251 W X'c�
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this/brm,I herebv ceru&that the well(s) was(were)constructed in accordance
with 15A NCAC 02C.0100 or I.iA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Y'es or ONo copy of'this record has been provided to the net/tun ner.
if this is a repair,Jill out known well construction information and explain the nature of the
repair under.21 remarks section or on the back of 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessan.
Hbr multiple injection or non-water.supply wells ONLY with the same construction,You can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'dtfjerent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
lfwater level is above 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" 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.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 form within 30 days ofcomplebon of
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
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