GW1-2021-02211_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Kevin White f��F
DESCRIPTION
Well Contractor Name ft. Wet
2973 ft.
NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells OR LINER if a Hcable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed400
FROM I TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 59 - ft. 2 in. SCh40 I PVC
List all applicable well permits(i.e.CounlY,State, Pariance,Injection,etc.) ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 59 ft- 61 ft. 2 1p' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 52 ft. Portland Cem Tremie
Non-Water Supply Well:
52 ft. 57 ft- Bentonite Chil Tremie
MMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. ft.
57 61 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
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,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
6-30-21 AS-21 ft. ft.
4.Date Well(s)Completed: Well ID# ft. R. r x"
5a.Well Location: ft. ft. g
Colonial Pipeline Company ft. ft. 1
0
Facility/Owner Name Facility to#(if applicable) f[ ft
14511 Huntersville-Concord Road, Huntersville, NC 28078 0u1ti11
1PG £S�
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 12"FMC
County Parcel Identification No.(PIN) - 2x2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field one lat/long is sufficient)
35.412834 N -80.807217 W
Signallur ofCenitied Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary gv.signing this fbrm, I hereby cerrifi•that the rrell(s)was(here)constructed in accordance
rrtih 15A N('AC 02C.0100 or MA N('A('02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EI No copy qJ this record has been provided to the ire/l owner.
1f rhis is a repair,fill out knouvi well construction infi-nuvion and explain the nature of 1he
repair under=21 renmrks section or on the back of.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•br muhiple injection or non-iraier supply wells ONLY frith tire.came construction,you cmt
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 61 24a. For All Wells: Submit this form within 30 days of completion of well
hur multiple wells list all depths iJ di#j rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
40 Division of Water Resources,Information Processing Unit,
(ft.)
IJ'rrarer level is abore casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY:i In addition to sending the form to the address in
8 1/4 HSA 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
13a.field(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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013