GW1-2021-07731_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
L Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3367 a. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING e6thermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 14 ft. 4 in. SCh40 PVC
List all applicable a-ell permits(i.e.Coun(v,Slate, Variance,injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14 ft' 54 R. 4 1O' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft.
❑Ind ustrial/Com mere ial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPL.ACEMENTMETHOD&AMOUNT
❑Itri ation 0 rt. 10 rt. Portland Cem Tremie
Non-Water Supply Well:
' 10 ft 12 t3. Bentoriite Chi Tremie
OMonitoring ❑Recover`
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
12 rt 54 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attachadditiotial sheets if tiecessa ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gtrain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. r _
10-20-21 RW-90 ft. ft.
4.Date Well(s)Completed: Well ID#
Ng5a.Well Location: ft. ft. JL2�
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. i;Nr T- -•-..,-,�,,
�%<+1, A;`il;rls�pi"'nhf
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21:REDf.*,RKS I'
Mecklenburg
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)
35.413506 N 80.807147 W
Signatm�o Ce hied 411 Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary HY.signing this/brm,I hereby cei,10)that the well(c)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Srandards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of/his record has been provided to the well owner.
/f this is a repair,Jill out known well construction information and explain the nantre of the
repair under-'21 remarks section or on the back c f this 1brnn. 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 nnrhiple injection or non-water supph,wells ONLY with the same construction,you can
submit one thrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 54 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths ijdi#erent(example-3 n 200'and 2C100') construction to the followinH:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
h'waler 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
6 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.) I
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 Wales Resources Revised August 2013