GW1-2021-02202_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White FR.ONATER TONES DESCRIPTION
Well Contractor Name
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER TIHCICNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 13 ft- 1 2 in. seh40 pvc
List all applicable well permits(i.e.Couniv.State,Variance,hn)eetion,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 13 It- 28 ft- 2 t"' 1 .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 6 Portland Cem Tremie
Non-Water Supply Well:
2Monitoring ❑Recover 6 ft. 11 fr. Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
11 ft' 28 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if ttecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color%hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 6-22-21 s)Completed: Well ID# PV-13 ft. 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 12"Cover n-0�gvo
County Parcel Identification No.(PIN) 2 X 2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field.one[at/long is sufficient) tt�U- 2A
35.412365 N -80.807066 W.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing/hiss lbrm, 1 hereby cer,that the well(s)uas(were)constructed in accordance
Walt 15A NCAC t/2C.0100 or 1jA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Fes or ElNo copy til this record has been provided to the well corner.
If this is a repair,Jill out known well construction inl6miation and explain the nature ol'the
repair under=21 remarks section or on the back o/this jornn. 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 necessarN
bbr multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one lbro. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nwhip/e wehs list all depths ifdijjerenl(exannple-3 a 200'and 2 a/00') construction to the following:
10.Static water level below top of casing: None (f1) Division of Water Resources,Information Processing Unit,
q'+rater level is above casing,use" " 1617 Mail Service Clenter,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA and 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,Underground 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 ofcomple[ionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 201