GW1-2021-02179_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY-
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. fL
2973 � ftt. ft.
NC Well Contractor Certification Number 2�21 115.FROMUTER CASING form I TODI,A aLed wells OR�ILiNER�S a h MATERIAL
Parratt-Wolff, Inc. ►��� L �# ft• I ft. in.
Company Name 1 33 fl>1 f��'✓s 16.INNER CASING OR TUBING eothermat closed-loop)
I�I r�ll�. `t t rtl�n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit p ft' 42 ft- 2 i" sch40 pVC
List all applicable well permits(i.e.(oun(y,State.Variance,Injection,etc,.) ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 42 ft. 62 ft. 2 in. .010 sch40 pVC
❑Geothermal(Hea[ing/Cooling Supply) ❑Residential Water Supply ft. ft. in.
(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 39 ft- Portland Cem Tremie
Non-Water Supply Well:
Rl Mon itori ng ❑Recoven 39 ft. 41 fit- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
41 ft 63 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage tt. fr.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG.attach additional sheets if neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack type,grain sire,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks)
4.Date Well 6/3/21 s)Completed: Well ID# MW-93 f`. ft.
ft. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4"Pro Cover
County Parcel Identification No.(PIN) '2 X2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one]at/long is sufficient)
35.414267 N -80.804281 W. (p ZZ 2�
Signs re of Certified Well Contactor - Date
6.Is(are)the well(s): Permanent or ❑Temporary
Hl'signing dtis Jbrm, /hereby certiJi,that the tre//(c)tax(u ere)constructed in accordance
with 15A N(A(02(.0100 or I SA N'A'02(.0200 Well Construction Standords and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy njthis record has been provided to the yell ou ner.
lf7his is a repair,Ji11 out known ael!construction inJarmation and explain the nature of the
repair under=21 remarks section or on the hack q1 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
I•itr multiple injection or non-water supply wells ONLY frith the same construction,tau cat)
suhma one_jarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 62 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nuulaple we/is list all depths if'diJjereni(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 52.5 (ft.) Division of Water Resources,Information Processing Unit,
4"vier level is above caring,use•• 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
8 1/4 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
m 13a.Yield
(gp ) 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: 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