GW1-2021-00245_Well Construction - GW1_20211213

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 40 ft. 159.5 ft• Wet
2973 ft fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ncable
RIAL MATE
FROM TO DIAMETER THICKNESS
Parratt-Wolff, Inc. ft. ft. 1 1 in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
WR0300120 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt• 1 g 5 rt 4 in. sch40 pvc
List all applicable well pernrits(i.e.County,Stale,Variance,hrjection,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 19.5 ft' 59.5 f" 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 14 e. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 14 rt 16.5 ft• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
16.5 59.5 #1.Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rt. ft.
.. ft. ft.
DEC,.
11-17-21 Well ID# RW-93 ft. r
4.Date Well(s)Completed: 9
1
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. �• i e'r:;�, Il'%)I
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. rt.
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 lat/long is sufficient)
35.412285 N -80.806265 W ,J (I a 7.
Sign ore of CertifiNd Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary gv signing this Jorm, 1 herehv certifv that the rrell(s)it (were)constructed in accordance
with 15A NCAC 02C.0/00 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo coP),o/7his record has been provided to the well owner.
#this is a repair,fill out known well construction information and explain the nature gf the
repair under'.21 remarks section or on the back gflhis form. 23.Site diagram or additional well details:
You may use the back of this page!to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1--or multiple injection or non-water supply wells ON1.Y wilh the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 59.5 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
Fbr mrdtiple wells list all depths ifdifferenl(example-3@200 and 2 cr 100') construction to the following:
I
10.Static water level below tap of casing: 40 (ft,) Division of Water Resources,Information Processing Unit,
/{'voter level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: IIn addition to sending the form to the address in
6 5/8 HSA , 4" PVC, &2vv S OOrIS 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground 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.
Form GW-I North Carolina Department of Environnvent and Natural Resources-Division of Water Resources Revised August 2013