GW1-2021-00382_Well Construction - GW1_20210315

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 37 f`' 50 f`' Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wens OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 35 ft- 2 in. sch40 PVC
List all applicable well pernnis(i.e.C'ounnt State,Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 "' 50 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I ft. in.
[ Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 fr. 31 ft. Portland Cem Tremie
Non-Water Supply Well:
ZMonitorine ❑Recovery 31 f` 33 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑A offer Storage and Recovery ❑Salini Barrier
q g ry ry 33 f`• 50 f`• #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,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
ft. fr.
4.Date Well(s)Completed: 12-23-20 Well ID# MW-68
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address:City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
35.413056 N -80.805275 W es. .-Z( • 4-.(
Signature of Certified We Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By.signing this./bra,1 herebv certify that the well(s)was(here)constructed in accordance
Wait I5A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy g1this record has been provided to the we//owner.
if this is a repair,fill out known well consiruction information and explain the nature of the
repair under::2/remarks section or on the back ofdiis forni. 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.
hbr multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one jnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr muhiple wells list all depths tfdiijkreni(example-9@200'mid 2 n l00') construction to the following:
10.Static water level below top of casing: 37 Division of Water Resources,Information Processing Unit,
//'water 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 & 2" spoons construction
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.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