GW1-2021-00394_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 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 ifa lieable
FROM TO DL4METER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rr. 10 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 25 ft- 2 in. .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
El Irrigation 0 ft. 6 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonnoring ❑Recovery 6 ft. g ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
8 f" 25 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/mck type,grain sin,etc.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft, ft.
4.Date Well(s)Completed: 12-7-20 Well ID# PV-05
ft. ft.
5a.Well Location:
ft. ft. �,! 4J
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 1 '
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS ,s '3'.•�,VI t
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient)
35.412244 N -80.806048 W �V �,} (•(6 • Z`
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this fbrm, 1 hereby certify that the well(s)uas(were)constructed in accordance
u nh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 111'es or i]No copy of this record has been provided to the well owner.
!(this is a repair,fill out known well construction information and explain the nature of 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 supp/v wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdif(erent(example-3 tt 200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
/Grater level is above casing,use- " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Inicetion Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA 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 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