GW1-2021-00388_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 41 ft' 46 ff wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 31 It- 2 in- SCh40 PVC
List all applicable hell permits(i.e.County,State. 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 31 ft' 46 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIv f. f.(sin le) m.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 27 ft. Portland Cem Tremie
Non-Water Supply Well:
- 27 rr 29 ft Bentonite Chil Tremie
❑O Monitoring ❑Recovers
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 29 fr. 46 ft. #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 size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 2/9/21 MW-75 ft. ft.
Completed: Well ID#
ft. ft. 4t
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ,
14511 Huntersvi Ile-Con cord Road, Huntersville, NC 28078 "
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:
(ifwell field,one lat/long is sufficient)
35.414285 N -80.804117 W.
Sign ure of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary gy,signing this form, l herehy certify that the well(s)was(were)constructed in accordance
n:uh l jA 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 q/tht.s record has been provided to the we//owner.
//this is a repair,fill out known well construction information and erplain the nature ql the
repair under 2/remarks sec lion or on the back o/'this forth 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1•or multiple injection or non-water.suppli,we//s ONLY with rive same construction,You call
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple we/h Its/al/depths ift4&reni(example-3 n 200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 41 (ft.) Division of Water Resources,Information Processing Unit,
1/'water lerel 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" 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 m Nlethod of test: 24c.For Water Supply&Injection Wells:
(gP ) 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