GW1-2021-00424_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 27 ft. 29 ft. Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 27 ft. 2 in. SC1140 PVC
List all applicable well permils(i.e.Comay.Seale, I%oriance.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 27 ft' 29 ft- 2 in. .010 sch40 PVC
❑Geothennal(Heating/Cooling Supply) ❑.Residential Water Supply ft. ft. in.
pp y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt 23 rt• Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery 23 ft- 25 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a Hcable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 25 ft' 29 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rack type,prain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 12-9-20 Well ID#AS-02
ft. ft.
5a.Well Location: T?
Colonial Pipeline Company ft. ft. 1 �.
Facility/Owner Name Facility ID#(ifapplicable) ,
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. 1
ft. ft.
Physical Address,City,and Zip ,�,Y-��•) 5i1
21.REDfARKS ,;f•'."i;�;;1 i"�%� _
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ha/long is sufficient)
35.412792 N -80.806405 W 6AA
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this dorm, 1 hereby ceriily that the we//(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0700 Well Construction Standards and ihou a
7.Is this a repair to an existing well: ❑Yes or EINo cow oJ'this record has been provided to the well owner.
IJ'this is a repair,Jill oat known well construction information and explain the native oJ'the
repair under.21 remarks section or on the back gJ'ihis Jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor malNple injection or non-water.supply wells ONI Y with the same canstruetinn,you car
submit one.Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 29 24a. For All Wells: Submit this form within 30 days of completion of well
I•br nauhiple wells list all depths iJ'dij/erew(example-3@200'and 1 ui 100') construction t0 the following:
10.Static water level below top of casing: 27 Division of Water Resources,Information Processing Unit,
{/grater level is abore casing,use"-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I Noah Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013