GW1-2021-07199_Well Construction - GW1_20211006

i
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. It-
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-eus OR LINER ifa Hable
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 ft. 9 R• 4 in. sch40 pvc
List all applicable well permits(i.e.County.Suite,I%ariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 "' 64 rt' 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 5 ft, Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 5 ft. ft- Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
7 e. 64 rt• #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/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 8-13-21 RW-78 ft. ft.
$)Completed: Well[D# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
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[at/long is sufficient)
35.413876 N -80.805465 W < • Z t
Sig aiure of Certified Well Contractor Date
6.Is(are)the well(s): 21"ermanent or ❑Temporary By signing this tbrm,I herebv cerul/ that the trell(s)was(here)constructed in accordance
truh 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards anti that a
7.Is this a repair to an existing well: ❑Fes or [?]No copy ofdtis retard has been provided to the well owner.
11 this is a repair,Jill out knotrn well construction information and explain the nature of the
repair under=21 remarks section or on the back of this,(orn,. 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.
For nit lliple injection or non-wafer supply wells ONLY trap the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 64 24a. For All Wells: Submit this Lform within 30 days of completion of well
Tor multiple wells list all depths tfdijjerent(eraniple-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 40 00 Division of Water Resources,Information Processing Unit,
it itaier level is above casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. [f
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013