GW1-2021-00384_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fbrm can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 ft• 65 ft• Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS DATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-limp)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft- 50 ft- 2 '"' Sch40 pvc
List all applicable hell permits(i.e.Comrly,State, 4criance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 50 r`• 65 ft. 2 in. .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 f" 42.5 ft. Portland Cem Tremie
Non-Water Supply Well:
❑Monitoring ❑Recovery 42.5 ft. 47 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f` r`
❑Aquifer Test ❑Stormwa[er Drainage 47 65 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardness,soil/rock type,pomin size,etc.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well 1/5/21 M W-71s)Completed: Well ID# _ E J
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. bI '
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft. G1ti.,r7 '^":1iri13 .t..✓'v J Y l
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient) / n
35.414153 Nr -80.804562 W1.
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,1 herebv certifv that the well(.$)rras(mere)constructed in accordance
with 15A NCAC'02C.0100 or 15A NCAC 02C.0200 Well('aisiructiai SiandarcLv and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gf 1his record has been prorided to the well owner.
!/this is a repair,fill out known well construction information and explain the nature o(the
repair under�21 remarks section or on the back g17his jbrm. 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 it/ection or non-water supple wells ONLY wiih the same construction,vat can
submit one 1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nathiple wells list al/depths if different(example-3@200'and 2 rt 100') construction to the following:
10.Static water level below top of casing: 37 (ft,) Division of Water Resources,Information Processing Unit,
l/water/ere/is above caving,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" split spoons 24a above. also submit a copy of this form wthin 30 days of completion of well
12.Well construction method: construction to the tollowing:
(i.e.auuer,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 ofcompletion of
13b.Disinfection type: Amount: well construction to the county health departVofthemy where
constructed.
Form GW-I North Carolina Department ofEnvironment and Natural Resources-Division ofWater ResourcesRevised August 2013