GW1-2021-07744_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
"ntis form can be used for single or multiple Hells
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i 1.Well Contractor Information:
Kevin White 14.WATER.ZONES
FROM TO DESCRIPTION
Well Contractor Name It. f4 i
2973 ft. fL
NC Well Contractor Certification Number I&OUITR,GISING`formuNkmillwelb ORL__ U ubk
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I , I in.
Companc Name 16.-INNER CASING OR.. ING:(evotherasill dweda"
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tr. 30 ft. 4 'n` SCh40 pcI,tn7 all upplic•able u•el/perntity(i.e.r bun(t•.Siote,f'oriance.Injection etc) D' ft. - in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 R` 45 ft. 4 In. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. ft.
(sin le)
❑industrial/Commercial ❑Residential Water Supply(shared) yR"GROUT
FROM TO MATERIAL EM PLACEM ENT METHOD&AMOUNT
❑irrigation 0 rt 25 1 Portland Cem Tremie
Non-Water Supply Well:
MMonitoring ❑Recovery 25 ft- 27 rL Bentonite Chil Tremie
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAW/GRAVEL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL, EMPLACEMENTMErHOD
rt•
❑Aquifer Test ❑Stormwater Drainage 27 44 D. #1 Sand Tremie
O. ft
❑Experimental Technology ❑Subsidence Control -
`=205•DR[fiT]NG'LOGI iddltioi6t1?iibeett_H" '- ::t, _
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCIHPnON color.hardness.saUrock type.Irain sire.etc.
0Gcothermal(Heating/Cool ing Return) ❑Other(explain under#21 Remarks) ft ft.
fr. ft. 1
4.Date Well(s)Completed: 8-27-21 well ID# RW-81
ft. ft.
5a.Well Location: (°tf =i I r)i•;
fr. rL Mr„)TPO r" CESSiie(S Uivi I
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 —ft. ft
"Physical Address,City,and Zip
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/secands or decimal degrees: 22.Certification:
(ifrvell field,one lat/long is sufficient)
35.413565 N -80.807031 W ,
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Signit—ture ofCenified Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Hv signing this fivnt,!hereby crrtiJy that the we!l(.r)wus(were)nnsstrucved in accordance
with 15A A •At'02C_0100 or ISA AVAC O •.0200 Well Construction Standank and that a
7.Is this a repair to an existing well: ❑Yes or EINo cony ol'dris record has been provided to the veil awner.
Ifjhis is a repair,fill out known n-ell construction inf rnnation and explain the native rftbe
repair under.:21 remarkv.vection or ran the back(y'this fi rm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l-or nudliple injection or non-,cuter supply,rolls ONLY with the same construction,von can
submit onefivm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wei Ls: Submit this form within 30 days of completion of well
Mu­mulNplemelLvli.cttrll:JLrihcifrlifJerenr(rmntple-30200'and?,0J001) construction to the following:
10.Static water level below top efcasing: 35 (ft.) Division of Water Resources,Information Processing Unit,
if water Jere/is abnre c•using,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 4 (in.) 24b.For Injection wells ONLY: I In addition to sending the form to the address in
„ 24aabove, also submit a copy of!this form within 30 days of completion of well
12.Well construction method: 6 5/8 HSA 8,2 spoons construction to the following: i
(i.e.auger,rotary.cable,direct push.ele.)
Division of Water Resources,IPpderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C nter,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 ofcompletion of
13b.Disinfection type: Amount: %veil construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Envimmnent and Natural Resources-Division of Water Resources Rcviscd.August 200
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