GW1-2021-07730_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used far single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 45 f" 1130 f`. f Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(formulfi-cased wells OR LINER if a licable
FROM TO DIAM ETER, THICKNESS MATERIAI.
Parratt-Wolff, Inc. ft. ft. tin.
Company Name 16.INNER CASING OR TUBING eothermal closed-lootal
FROM TO I DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 110 ft']_2 '"' SCh40 PVC
/Jo all applicahle well pennon(i.e.Coun,,Sia/e.Variance,Injection,etc.)
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 110 f`' 130 f`. 2 "' 1 .010 1 SCh40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) tt ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENTME'I HOD&AMOUNT
❑Irri ation 0 ft• 96 ft• portland cem Tremie
Non-Water Supply Well:
❑Monitoring ❑Recovers'
96 ft• 101 ft• Bentonite chif Tremie
Injection Well: 135 f` 150 f` Bentonite Chi Tremie
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 102 f`• 135 f`• Sand pour
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culm,hardness,soil/ruckt r, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 7-28-21 Well ID# MW-16D
rt. rt.
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility IDt!(ifapplicable) NOV 16 ft. ft. ,
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip III
t;I
21:REMARKS `.e''hYhf+1 �h �t^i�Mecklenburg ✓VI_JJII\'l,
9 2 X 2 pad&"'Flush Cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(it'well field,one tat/long is sufficient) , ` Q
N W U'
Sign ature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary g X / f' (J ( J
Hv.ri min this arnn,/lrerebv cerli Ina!dte Ire//s wus here carrlrucred in accordance
+ride 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 E]No copy q/this record has been prorided to the Irel/owner.
//'this is a repair.fill out known troll con iruction intbrinalion and explain the nacre ol'!he
repair under:r21 remarks section or on the hark o/'lhis fornt. 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: construction details. You may also attach additional pages if necessary.
l-'or multiple injection or non-water supply trelk ONLY wish the sane construction,you can
submit one/grin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 130 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nudtiple Irel/.r list all depths i/di//eren!(example-3@ 200'and 2@I00') construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
I/wafer/ere/is ahore casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the torn to the address in
6 5/8"pve casing &6"Air Hammer 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 Centrq 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 ofcompletionof'
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