GW1-2021-00421_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 43 it' 47 ft. Wet
2973 rt. 1 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if o licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 17 ft. 4 in. seh40 pvc
List all applicable well pernins(i.e.C'oanttt State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 ft' 47 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 13 ft. Portland Cem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
13 ft. 15 ft. Bentonite Chi 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
15 ft' 47 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,sail/rock e, rain size,etc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-20-21 Well ID# RW-54
rt. ft.
�m
5a.Well Location: ft. ft. •„( '_ +'.�
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 Physical Address,City,and Zip c�rn'. s jII'e'
2l.REMARKS
Mecklenburg U,.a�`
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) ,\
35.413228 N -80.806007 W
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing tits Jorm, I herebv certify that the well(s)was(were)constructed in accordance
with I5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy oJ'ihis record has been provided to the well owner.
IJ this is a repair.Jill oat known well construction in%rmation and explain the nature qJ the
repair under r2l remarks section or on the back oj7hisJorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nmhiple it iection or non-water supply wells ONLY with the same construction,von can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 47 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muinple wells list all depths t/ail
Jerem(example-3 00'any/2@ I00') construction to the following:
10.Static water level below top of casing: 43 (ft.) Division of Water Resources,Information Processing Unit,
tfivater level is above casing,use"-" 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 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-I636
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 daysofcompletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013