GW1-2021-00393_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin Whitei4.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name f[. ft.
2973 ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING for multi-cased wells OR LINER ifa livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loon)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 2 i" SCh40 pvc
List all applicable o,ell permits(i.e.C'ounw,State, Variance,lnjeclion,elc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 f`' 25 ft- 2 in. .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
❑Irri ation 0 ft. 6 ft- Portland Cem Tremie
Non-Water Supply Well:
2Monitoring ❑Recovery 6 f` 8 f` Bentonite Chil Tremie
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO
8 ft' 25 ft. MATERIAL EMPLACEMENT METHOD
#1 Sand Tremie
❑Aquifer Test ❑Stormw'ater 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.
ft. ft.
4.Date Well 12-8-20 PV-04s)Completed: Well[D# �-.a.
( a
5a.Well Location:
Colonial Pipeline Company rt. ft. 1 202
Facility/Owner Name Facility ID#(ifapplicable) ft. ft 11
14511 Huntersville-Concord Road, Huntersville, NC 28078
a
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:
(ifivell field,one]at/long is sufficient)
35.412317 N -80.806316 N. ,��
Signature ofCertitied Well Contractor Date
6.is(are)the well(s): 1211permanent or ❑Temporary, BY signing this form, I herebv cerli&that the wel/(s) was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction S7andards and that a
7.Is this a repair to an existing well: ❑Yes or EI No copy of this record has been provided to the well owner.
Y this is a repair,fill out known well cmnsiruclion information and explain the nature at the
repair under=21 remarks section or on the back of this form. 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 injection or non-water supply it ells ONLY with the same construction,You can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiifferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
//'water level 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 m Method 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