GW1-2021-02207_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:
14.WATER ZONES
Kevin White FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 e. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased welts OR LINER if a ticsble
FROM TO DIAMETER TIIICFGNESS \tATER1AL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 28 ft. 2 in. sch40 pvc
List all applicable❑,ell permits(i.e.Couniv,State, Variance,Injection,etc•.)
ft. ft. - in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'"
❑Agricultural ❑Municipal/Public 28 1" 30 ft' 2 ' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 24 ft- Portland Cem Tremie
Non-Water Supply Well:
24 ft 26 ft Bentonite Chil Tremie
ZMonitoring ❑Recover,
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a h'cable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. fr.
26 30 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheefs'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. fr.
4.Date Well(s)Completed: 6-17-21 Well ID#AS-16 ft. ft.
ft �.�
. ft.
5a.Well Location:
Colonial Pipeline Company ft. fr. d 2
Facility/Owner Name Facility 1134(ifapplicable) ft. fr. _
14511 Huntersville-Concord Road, Huntersville, NC 28078 U tlt
Physical Address,City,and Zip ^ ,�•` ar,0�
21.REMARKS w
Mecklenburg 12"Cover
County Parcel Identification No.(PTN) 2 X 2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one tat/long is sufficient)
35.412252 N -80.806403 W.
Signal re of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this./arm, I herebv certllY that the well(s)was(were)constructed in accordance
wish 15A NCAC 02C.0100 or 15A N('AC 02C.0200 Well Consiruciion Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy gl'this record has been provided to the ire//owner.
It this is a repair,Jill out known well construction inlornuuton and explain the nature q/the
repair under�21 remarks section or on the back of 1his form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
bar multiple injection or non-water supply wells ONLY with the same construction,you can
submit one./orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-'or multiple u•el/s list all deplts ijdiJjerent(example-3 a.N10'and 2@100') construction t0 the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
If traier level is above casing,use--" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection 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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013