GW1-2021-02176_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: VIN
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2973 JUL + 2021 ft. ft.
NC Well Contractor Certification Number r(a,$51n�V��� 15.OUTERCASING for multi-cased we115).0LINER ifa ticable
Parratt-Wolff, Inc. Ir�,tar 'anr p��ser+Y'0n FROM ft TO ft DIAMETER to THICKNESS MATERIAL
Company Name Y 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 4 in. sch40 pvc
List all applicable we//permits(i.e.County,Slate, Variance,Injection,e2•.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 f" 35 ft' 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 6 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑RecoverN, 6 ft. 8 ft. Bentonite Chil Trernie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8 ft 35 ft #1 Sand I 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.
ft. ft.
4.Date Well(s)Completed: 5-28-21 Well ID# RW-69
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
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)
35.415642 N -80.805574 W. t D _ 0 F ZZ Z
S mature of'Cenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing Ihic.%orm, I herehv certify that the well(s)eras(were)consinicted in accordance
irah 15A N'AC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis record has been provided to the❑e//owner.
I/'this is a repair,fill out knoivn we//construction information and explain the nature of the
repair under-21 remarks section or on the back ojthis farm. 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 necessary.
For multiple injection or non-water supply welly ONLY[rink the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1•br mu/lip/e o elly li.vi a/I depilty iJ clijlerent(eraniple-3 n100'mid 2 a I00') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Limit,
q hater lerel is above casing,use' - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA& 2" SpOOnS 24aabove- 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;Underground Injection Control Program,
FOR WATER SUPPLY"WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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