GW1-2021-00389_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 35 ft 45 2= Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a &cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. It. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 25 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.Uounty,State, Variance,Injection.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply YY'ell: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 ft' 45 ft- 2 1n' 1 .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑liri ation 0 ft' 21 1 Portland Cem Tremie
Non-Water Supply Well:
ZMonitoring ❑Recovery 21 rt. 23 ft. Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. ft.
23 45 #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 Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 2/10/21 MW-76 ft. ft.
Completed: Well ID# p j
5a.Well Location: ft. ft. _
Colonial Pipeline Company ft. ft. MAR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 4"Stick up cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one tat/long is sufficient) IL
35.414299 N -80.804067 W ���� Z Zd Z
Signatare ofCeitified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this Jorm,I herebv certify that the well's)was(were)constructed in accordance
n ilh 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well C'on.struction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the we//owner.
ll'this is a repair,Jill out known well construction information and explain the nature glthe
repair under--21 remarks section or on the back q/this Jorm. 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.
For multiple injection or non-water supp/e wells ONLY with the same construction,-ran can
submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bor multiple wells list al/depths ifdi(Jerent(example-3@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 35 Division of Water Resources,Information Processing Unit,
I/water level 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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 2013