GW1-2021-07200_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple Hells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 f3. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-weds OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 fr. 16 ft. 4 in. Sch40 pvc
List all applicable hell permas(i.e.Uounty,Stale, Variance.hryectiun,etc.)
ft. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft' 56 r" 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 12 ft. Portland Cem Tremie
Non-Water Supply Well:
12 ft 14 ft Bentonite Chil Tremie
Monitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
14 fr 56 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑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.
ft. ft.
Date Well(s)Completed: 8-12-21 Well ID# RW-77
Sa.Well Location: ft. ft.
Colonial Pipeline Company rt. ft.
Facility/Owner Name Facility ID#(if applicable)
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 ladlong is sufficient)
35.413806 N -80.805491 W . Z
Sig ature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary BY signing llnls Jorm, I herebv certii i,that the vell(s)vas(were)constructed in accordance
frith 15A NCAC 02C.0100 or 15A NC•AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑V es or ElNo copy of this record has been provided to the is owner.
If this is a repair,Lill out known well construction i?1brnnation and explain the nature gl'the
repair under 21 remarks section or on the back ofthis Ibrm. 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 multiple injection or non-water.sitpply yells ONLY with the same construction,you can
.submil one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 56 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fbr mulliple wells list all depths tfc#l(erent(example-3@200'and 2 a/00') construction to the following:
10.Static water level below top of casing: Unknown (ft) Division of Water Resources,Information Processing Unit,
q*waler level a 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" spoons24aabove, 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,'lUnderground 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&In_jectiolI Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013