GW1-2021-00396_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Intemal 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 ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 13 ft. 2 in. sch40 pvc
List all applicable well permils().e.CounN.Stale,I%ariance,Injection,etc.J
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft. 28 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
❑Irri ation 0 ft. 9 It- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recoven, 9 ft. 11 ft- Bentonite Chil 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 11 ft 28 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage rt. 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.
4.Date Well 12-6-20 PV-07 ft. ft.
$)Completed: Well ID# _
ft. f[. �`:_,,'� �- '•...� lot, �:.:✓t
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft. I mu
Facility/Owner Name Facility ID#(if applicable) ft ft + �(
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. ',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:
(if well field,one[at/long is sufficient)
35.412497 N -80.805866 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
8v signing this Jornt, 1 herehY certify that the wells)was(}rere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 1/2C.0200 Well Consiruction Standards and Thal a
7.Is this a repair to an existing well: ❑Yes or 91 No copy of this record has been provided to the well o+rner.
ljthis is a repair,Jill out known well construction informolion and explain the nature ql the
repair under=21 remarks.section or on the back of this Jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or vvell
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Tor multiple i»leclioti or non-u,aler supply wells ONLY with the same construction,you can
submit one./orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 24a. For All Wells: Submit this form within 30 days of completion of well
Ibr nnilliple wells list all depths iidilPrenl(example-3 a 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,
I/lraler level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection 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 Environnient and Natural Resources-Division of Water Resources Revised August 2013