GW1-2021-02210_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:
14.WATER ZONES
Kevin White FROM TO DESCRIPTION
Well Contractor Name 30 rt. 49 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased sells OR LINER if a licable
FROM TO DIAMETl ER THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tr. 47 ft• 2 in. Sch40 pvc
List all applicable well permits(i.e.Count.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 47 ft- 49 ft• 2 in. .010 Sch40 pvc
❑Geothermal Heatin Conlin Supply) ❑Residential Water Supply(single)
ft. f]. in.
( g/ g PP Y) PP Y g
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLaCEMENTMETHOD&AMOUNT
❑Irrigation 0 ft' 43 ft- Portland Cem Tremie
Non-Water Supply Well:
43 f` 45 ft Bentonite Chil Tremie
OMonitoring ❑Recovero
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
f`
❑Aquifer Test ❑Stormwa[er Drainage 45 ft' 49 #1 Sand 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.gmin sim,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. R.
4.Date Well 6-23-21 AS-19 ft. ft.
$)Completed: Well ID#
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) d
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 •r, - s��9
ft. ft.
Physical Address,City,and Zip t ij• t ���r
21.REMARKS
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[atflong is sufficient)
35.412371 N -80.807127 W. 0047. I
Signature o Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this lbrtn, I herebv ceruft that the trell(s)tras(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gl this record has been provided to the well corner.
Ifihis is a repair,fill out known well construction information and explain the nature gfdte
repair under 21 reniarkv section or on the hack g/iris fotrm. 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 iiection or non-tearer supply u•e/tv ONLY with the same construction,a can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 49 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
har multiple wells list all depdns ij di#J rem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
l/water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA and 2" SpOOnS 24a above, 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:
IgP ) 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 count),where
constructed.
Forst GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised.August 2013