GW1-2021-07198_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER ifa ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I iin.
Company Name 16.INNER CASING OR TUBING faeothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 et• 4 in. sch40 pvc
List all applicable well pernnis(i.e.C'oun(v,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 50 f` 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ff. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 11 ft• Portland Cem Tremie
Non-Water Supply Well:
11 ft 13 ft Bentonite Chil Tremie
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
13 50 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addition sheen;if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 8-5-21 s)Completed: Well ID# RW-76 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. ( 16%,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 tat/long is sufficient)
35.415317 N -80.806678 W.
Signat re of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By.signing this form, I herebv certiA,that the well(s)was(were)constructed in accordance
with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided it)the well owner.
/fthis is a repair,Jill out known is construction inlbrmation and explain the nature of the
repair tinder=21 remarks section or on the back of dory/orm. 23.Site diagram or additional well details:
You may use the back of this page ito provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l,or multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneforn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iil'di/ferem(example-3 200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
ry stater level is above easing,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 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 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