GW1-2021-00387_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 133 ft' Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 "' 18 ft. 2 in. SCh40 PVC
List all applicable hell pernrhs(i.e.Comnw.Slate, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 ft' 33 fit- 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 EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft' 13.5 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
13.5 ft. 15.5 "L Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Iicable
FROM TO MATERIAL EMPLACEMENT METHOD
15.5 33 #1 Sand Tremie
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft• ft
❑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 size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 2/8/21 s)Completed: Well ID# MW-74
ft. ft.
!art 7
5a.Well Location:
Colonial Pipeline Company ft. ft. _
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
2021
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft. _ 1" I'
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 8°FMC
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
35.414272 N -80.;'804149 W �,�_ L�'� Z ��
Sig ture of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this Jbrm,I hereht,c•erli/i,that llte tre//(c)eras(trere)consirucleel in accordance
will;15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consiruction Standords and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy qJ this record has been prorieled to the well owner.
If this is a repair,Jill out knmrn well construction inJormalion and explain the nature of lite
repair under 21 remark+section or on the back q/'ihis.Jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1,or nndliple oyec•tion or non-water.supplt,wells ONLY with the same construction,You can
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 33 24a. For All Wells: Submit this form within 30 days of completion of well
/•or muhip/e tre/Is list all depths ijdiJPreni(c vample-3 a'200'and 2 ro 100') construction t0 the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
I(uvater sere/is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA & 2" split spoons 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.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 hype: 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 201