GW1-2021-07733_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
L Well Contractor Information:
14.Gary Ellingworth FROM ER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft.
3367
NC Well Contractor Certification Number 15.OUTER CASING for mtilti-cased',wells 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 TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 11 ft. 4 '"' SCh40 I PVC
List all applicable sell permits(i.e.Cottmy.State,Variance,brleciion,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 rr' 36 ft. 4 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. 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:
OMonitoring ❑Recovery ft 9 it Bentonite Chi Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
9 36 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fr.
4.Date Well(s)Completed: 10-18-21 Well ID# RW-88
fr. fr.
5a.Well Location:
Colonial Pipeline Company 3 (,1 ;;,
Facility/Owner Name Facility ID#(ifapplicable) . ft. It;:hrl''j'•,IinPl(-"''t`,+`t=ti''V,:U
„ 1.�..., - r it
ft l
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. fr.
Physical Address,City,and Zip
21.REMARKS .
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)
35.413520 N -80.807044 W c,
Signature o enitied Well'Contractor - Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing Ihir jbrnr, 1 hereby certify that the sel/(s)it (,were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Consiructlon.Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZINo copy oJ'ihis record has been provided to the se//owner.
1J7hi.s is a repair,Jill out known it construction information and erpli in the nature of the
repair under:21 remarks section or on the hack oj'this.lorm. 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 yells ON/Y with the same construction,you can
suhnii one.lorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple sells list al/depths/fth ferent(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,
{/'crater 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 construction
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the tollowing:
(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
1
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 type: Amount: well construction to the county Health department of the county where
constructed.
9
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water°Resources Revised August 2013