GW1-2021-00419_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal 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 35 ft. 38 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 23 ft- 4 '"' Sch40 PVC
List all applicable well pernrity(i.e.County,State, Variance.lgieetion,etc.)
ft. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 23 ft. 38 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 17 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitorina ❑Recoven•
17 ft- 20 ft- Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage 20 38 ft. #1 Sand Tremie
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 Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 1-19-21 s)Completed: Well ID# RW-52 ft. ft.
rt. ft.
5a.Well Location:
rt. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. v
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. „ ,
Physical Address;City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35.413242 N -80.806018 N;
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this Lorin, 1 hereby certtfv that the well(s)was(sere)constructed in accordance
sith 15A NCAC 02C.0100 or I5A NCAC I/2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oJ'dns record has been provided to the well owner.
U this is a repair,Jill out known well construction in(ormaion and explain the nature gjthe
repair under=21 remarks section or on the back q/7hi.v fbrm. 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-saier.supply wells ONLY frith the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 38 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mithip/e wells list all depths ii(dillereni(example-3 tr 200'am/2@100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
tfwaterlevel is above casing,uve" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA and 2" spoons24aabove. 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013