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HomeMy WebLinkAboutGW1-2021-00393_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