GW1-2021-07732_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 d
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1.Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3367 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedtwells OR LINER ita licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. in.
Compan Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 11 ft. 4 '" SCh40 I PVC
List all applicable well permits(i.e.County,State,Variance,hy'ection,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 11 f`• 41 f`• 4 in. .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f` in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 7 ft- Portland Cem Tremie
Non-Water Supply Well:
ry 7 fr. g f`• Bentoriite Chi Tremie
OMonitoring ❑Recove
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
9 41 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionelsfteets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION lcolor.hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 10-19-21 s)Completed: Well ID# RW-89 ft. ft.
tr. ft.
5a.Well Location: ft. ft. R lz9
Colonial Pipeline Company ft. ft. t
Facility/Owner Name Facility ID#7(ifapplicable) ft. ft. IVLJV A2021
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS p
Mecklenburg it r
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.413520 N -80.807044 W '`� �. �•Z \
Signature of rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv,sig,, ..form, 1 hereby cerg1j,that the trell(s)was(mere)constructed in accordance
with I5A NCAC i11C.0100 or 15A NCAC 01C.0200 Well Construction Stmndards and rival a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has been provided to the well owner.
//'this is a repair,Jill out known well construc•lion h formation and explain the native q/the
repair under=21 remarks section or on the back o'this jorm. 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 supply wells ONLY with the same construction,you can
submit one/orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 41 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths i1*dillerent(example-3@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lj,rater level is above casing,use"-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA& 2" spoons construction
above, also submit a copy of this form ,ithin 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection hype: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013