GW1-2021-02204_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 f`' f`
NC Well Contractor Certification Number 15.OUPER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. rt. rt. in.
Compann Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 2 in Sch40 I PVC
List all applicable well permits(i.e.('aunty,State.Variance,h lec•tion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 25 ft- 2 'n .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 rr. Portland Cem Tremie
Non-Water Supply Well:
3 r`• 8 ft- Bentonite Chil Tremie
O Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 f`• 25 f`• #1 Sand _ Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"attach addifiotisl sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soillrock type,grain size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 6-24-21 s)Completed: Well ID# PV-15 ft. ft.
ft. ft.
5a.Well Location: ft. ft. -�.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. O�
t�
14511 Huntersville-Concord Road, Huntersville, NC 28078 R. ft.
JUL
Physical Address,City,and Zip 21.REMARKS U �
Mecklenburg 12"Cover
County Parcel Identification No.(PIN) 2 X 2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one tat/long is sufficient) L��
35.412969 N 80.807252 W. t 1
Signatu ofCertitied Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary BY signing Ihic fbrm, I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.02(l0 Well Consinietion SlandardS and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ol'this record has been provided to the well owner.
/fihis is a repair,Jill out known well con.siruction in/brmation and explain the nature g17he
repair under:21 remarks section or on the back gjlhis 1brm. 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 wells ONLY with the same construction.You can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths it di#J rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
4 water level is above casing,use- " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 246. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA and 2 spoons 24aabove, also submit a copy of this form within 30 days of completion of well
1 Z.Well construction method: 11 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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201