GW1-2021-07737_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
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 a. ft. E
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased*ells OR LINER if a 7ieable
FROM TO DIAMETER- THICKNESS MATERIAL
Parratt-Wolff, Inc. fI. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 18 ft. 4 in. SCh40 PVC
List all applicable irell permits(i.e.Cbuniv,State,Pariance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 ft' 58 ft. 4 tn' 1 .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 rt. 4 ft Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 4 ft. 6 f' Bentonite Chi Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
6 fr. 58 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attachiadditionel sheets if-necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type.grain sin,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
10-12-21 RW-85 f`' f`' ��
4.Date Well(s)Completed: Well ID#
5a.Well Location: R. ft. 20
21
Colonial Pipeline CompanyMin
Facility/Owner Name Facility ID4(ifapplicable) ft. ft. 1,11 Jt_V IiJI'J
14511 Huntersville-Concord Road, Huntersville, NC 28078 IfaFOn 'AT;1 I;;)n�t-�n
ft. ft. v UJIiVI Il(elI
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 Iat/long is sufficient)
35.413565 N -80.807031 W ( D Z
Si nature ol'CertifiedAVell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 herehv c•ertih,that the are/l(s)was(were)constructed in accordance
u"th 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 lNo copy glllus record has been provided to the well owner.
1J'this is a repair,fill out known well construction information and explain the nature of the
repair under=21 remarks.section or on the back o/'thi.s form 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.
f or mahiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 58 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'dijJerent(example-9@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
4 water level is above casing,rise..-•• 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" spoons24aabove, 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&InjectionWells:
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
consti uc[ed.
For GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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