GW1-2021-00244_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 f`' 47 f`' I Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LLNER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ; in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 32 ft- 4 in. sch40 PVC
List all applicable well perwas(i.e.County,Stale,Variance,htlection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 32 f" 47 ft. 2 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
❑irri ation 0 rt. 28 ft- Portland Cem Tremie
Non-Water Supply Well: 28 ft. 30 ft- Bentonite Chii Tremie
OMenitorine ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
30 f` 47 f` #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
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 421 Remarks) ft. ft.
4.Date Well(s)Completed: 9-16-21 Well ID# MW-94
5a.Well Location: Er
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 6°stick up Cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field one[at/long is sufficient)
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35.415916 N -80.804501 w
Signature of Certified Well Contractor Date
6.1s(are)the well(s): [OPermanent or ❑Temporary By.signing Ihis,lorm,I hereby cem6 that the weH(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Slandar&and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oil'this record has been provided to the well owner.
#this is a repair/ill out known we/l construction in(otanalion and explain the nature of ilte
repair under=21 remarks section or on the back ol'this form. 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.
Far muhiple injection or non-waler.supply wells ONLY with the same construction,_van can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 47 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For nndliple wells list all depths iiJ(##ereni(example-3 a 200'and 2 a 100') construction t0 the following:
10.Static water level below[op of casing: 37 (ft,) Division of Water Resources,Information Processing Unit,
/(water/erel is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: 'this
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.)
Division of Water Resources,Vuderground 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:
i.
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