GW1-2021-00246_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
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1.Well Contractor Information: ;
Kevin White 14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 6D ft. Wet
2973 rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
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 tt. 15 ft- 4 in. SCh40 PVC
List all applicable well perntles(i.e.County,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 15 ft' 60 ft" 4 in.' .010 1 SCh40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 11 ft- Portland Cem Tremie
Non-Water Supply_We1L• ---- --
OMonitoring ❑Recovero 11 It- 13 ft Bentonite Chi 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
13 ft- 60 ft. #1 Sand Tremie
❑AquiferTest ❑StormwaterDrainage 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 size,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks ft. ft.
ft. ft. 4-c, C,..i. r `rs.{.(._._I, i•
4.Date Well(s)Completed: 9-28-21 Well ID# MW-96
ft. ft.
5a.Well Location:
Colonial Pipeline Company ft.
Facility/Owner Name Facility ID#(ifapplicable) •- ,
ft. ft. � `;.`� i :/d3i.t, i It�l�•,, ',Fts.7(l7a
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 IaUlong is sufficient)
35.415589 N -80.806413 W �p Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IOPermanent or ❑Temporary ijv signing this/brm, 1 herebv cerlifi that the well(+)was 6 ere)constructed in accordance
triih 15A NC'AC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and lhat a
7.Is this a repair to an existing well: ❑Yes or ONo copy oflhis record has been prortded to the well oumer.
I/7his is a repair,fill oul known well construction in%rmation and explain the nature of the
repair under a21 remarks section or on the back q/'lnis%ornn. 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 maniple injection or non-waler supply ire/ls ONLY with the same construction, it call
submit one forme SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this''form within 30 days of completion of well
For multiple wells list all depths ijdifJerem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
4 irater level is above casing,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
6 5/8 HSA 8 2" spoons construction
above, also submit a copy of Ithis 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 C i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water Supply&Injection Wells:
Also submit one copy of this fori'n within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county heIalth department of the count),where
constructed.
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Form GW-I North Carolina Department ofEnvironnient and Natural Resources-Division of Water Resources Revised August 2013