GW1-2021-07736_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.Well Contractor Information:
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Gary Ellingworth FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
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3367
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Hcable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 4 1n. SCh40 PVC
List all applicable well permits(i.e.C'ounly.Stale, Fariance,l leclion,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 10 ft- 60 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[ irrigation 0 ft. 4 ft. Portland Cem Tremie
Non-Water Supply Well:
4 ft. g fr. Bentonite Chil Tremie
OMonitoring ❑Recoven
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
8 60 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets iEeecessa ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rack type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
10-14-21 RW-86 ft. ft. _
4.Date Well(s)Completed: Well ID#
ft. ft. I-
5a.Well Location:
Colonial Pipeline Company ft. ft. IVUV 1 6 70
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 -
ft. ft.
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:
(if'well field.one[at/long is sufficient)
35.413593 N -80.806959 W
Signature ofCei tied Well Contillactor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this Jitrni, 1 hereby cerli/b that the we//(s)was(were)constructed in accordance
wtth 15A NCAC CIX.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZlNo copy of'this record has been provided to the well owner.
4'Ihis is a repair,Jill ow known well construction igl6rmalion and explain the nalare ol7he
repair ender=21 renmrks section or on the back o/'this/orm. 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.
1,'or multiple inieclion or non-water supp/y+Fells ONLY with the,came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far ma/rip/e wells list all depths iJ"diJPrent(example-3 m 00'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use"-" 1617 Mail Service Tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY:j In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 5/8 HSA& 2" spoons construction to the fallowing:
(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
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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 Water Resources "- Revised August 2013
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