GW1-2021-07738_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This form can be used for single or multiple wells
1.Well Contractor Information: i
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft• ft. k
i
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft- 10 ft. 4 in. SCh40 PVC
List all applicable well permits(i.e.Comtnt State,Variance,Injection,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' 50 ft 4 '"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Comm ercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 6 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 25 ft 27 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licihle'
FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Recovery ❑Salmi Barrier
q g ry ty 27 rt. 44 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG attach additional sheet'if necessary)_
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 10-12-21 RW-84 ft. ft.
Completed: Well ID# ft. ft.
5a.Well Location: ft• ft. d /
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ;uc�iiUhJ
ft. ft. I 'FOpes n d a
Physical Address,City,and Zip 21.REMARKS ;; "vvL+�J11V(J sjy i'I
Mecklenburg
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)
35.413565 N -80.807031 W g
Signature ofCertitied Well t-ontractor Date
6.is(are)the well(s): IZPermanent or ❑Temporary BY sighting this form,I hereby c•erli/i that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy o/this record has been provided to the mell owner.
4 this is a repair,./ill out known we/1 construction igl6mu Lion and explain the nature o0he
repair under 21 rentarks section or on the back q/7hic Joan. 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.
hbr muhiple injection or non-swaler.supply a ells ONLY with the same construction,You can
submit oneJortn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hrelts list a//depths iJ dij(ereni(example-3C200'and 2 @/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
tf iraier 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" spoons24aabove, also submit a copy ofithis form within 30 days of completion of well
12.Well construction method: construction to the tollowmg:
(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
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.
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of water Resources Revised August 2013