GW1-2021-07741_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
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1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
h
Well Contractor Name ft. ft. I '
2973 ft. ft. 9
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ; in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 17 ft- 4 '" SCh40 pvc
List all applicable well permits(i.e.C'ountr,Slate,Parlance,Infeclion,etc.) f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 "' 72 f" 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 13 ft- Portland Cem Tremie
Non-Water Supply Well:
13 fL 15 ft Bentonite Chil Tremie
EMonitorine ❑Recover
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PAC K(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R.
❑Aquifer Test ❑Stormwater Drainage 15 72 #1 Sand Tremie
ft. ft.
❑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 sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
9-16-21 RW-83 ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft ft e I,f 1
Colonial Pipeline Company NOV 1 E
Facility/Owner Name Facility ID4(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. G :F?ScCTl�P1
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No cover
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one[at/long is sufficient)
35.415954 N -80.805575 W . Z
Signature of Certified ell Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hv.signing dos./firm,1 hereby cerlif),that the well(s)wac(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siandarch and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of tris record has been provided to the well owner.
if ilti.v is a repair.fill out known well construction information and explain tie nature of die
repair under=21 remarks.section or on the back q/'this Jorni. 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 necessar\.
for muhiple infection or non-water supply wells ONLY with the same construction,}you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 72 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
for nnihiple wells list all depths ifc/i/Preni(example-3 n 200'and 2@100') construction to the following:
10.Static water level below top of casing: 37 Ift•) Division of Water Resources,Information Processing Unit,
rylwaler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: iln addition to sending the form to the address in
6 5/8 HSA & 2" spoons24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccinter,Raleigh,NC 27699-1636
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13a.Yield(gym) Method of test: 24c.For Water Supply&In_iection�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 G W-I North Carolina Department of Environmem and Natural Resources—Division of Water Resources Revised August 2013