GW1-2021-00391_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple swells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 7.5 ft. 2 in. sch40 pvc
List all applicable well permits(Le.Cotonv.Stale, Variance.Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.5 ft. 22.5 ft- 2 i"' 1 .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 rr. 3 5 1 Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovers 3.5 ft 5.5 f` Bentonite Chi Tremie
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 5.5 ft• 22.5 ft• #1 Sand Tremie
❑Aquifer Test ❑StormwaterDrainage 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 tv e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12-9-20 s)Completed: Well ID# PV-02 ft. ft.
5a.Well Location: ft. ft. T A
Colonial Pipeline Company ft. ft. r-tli{�t t
IR 1 J 2
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
Physical Address,City,and Zip •-'
21.REI1fARKS
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(it well field one lat/long is sufficient)
35.412529 N -80.806391 N; �
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By.signing this Dorm,1 herehv cerri(i-that the uell(s)was(were)constructed in accordance
with l5A NCAC 02C.0100 or 1 SA NCAC I/2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or (Z]No copy gJ this record has been provided to the trell owner.
If this is a repair,Lill out known well construction inlnrmation and explain the nature of the
repair under .21 remarks section or on the back g1'ihis Jorm. 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.
I-or multiple injection or non-waler supply we1Ls ONI-Y with the same construction,you can
submit one jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 22.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor malt/ple wells list all depths i/'diJferent(example-3@200'and 2 a l00') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
Ilwarerlevel 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 24a 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: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 type: Amount: well construction to the county health department of the county where
constructed.
Forst GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201