GW1-2021-00378_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 20 ft' 22 ft' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Companc Name 16.INNER CASING OR TUBING geothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft. 2 in. sch40 pvc
List all applicable uvell pernriis(i.e.CoamhY,State, D'ariance,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 20 R. 22 R• 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. f. in.
(sin le)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 16 ft. Portland Cem Tremie
Non-Water Supply Well:
oMonitorine ❑Recover•
16 ft- 18 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. MATERIAL EMPLACEMENT METHOD
FROM TO
❑Aquifer Test ❑S[ormwater Drainage #1 Sand Tremie
18 ft. 22
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soilimck type,gamin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well 12-9-20 AS-04s)Completed: Well ID# ,
5a.Well Location: ft. ft. its "''
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
,Physical Address City, p ^t1s''1 y ry,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)
35.412578 N -80.806386 W. � 60 ( • l Z l
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary BY signing ihis Joan, 1 hereby certi/i that the well(s)eras(were)constructed in accordance
nrilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or 0 No copy q/this record has been provided to the nre11 onrner.
IJ dti.s is a repair,fill aui known yell consirucoon inlormaion and explain the nature of the
repair tinder=21 remarks seciton or on the back q/'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 necessan.
For muhiple injection or non-nrater.supnly nrelis ONLY frith the Name eonstruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 22 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
biir multiple nrells list all depths it diJJereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
1/\rarer level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Infection 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,rotarv.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 Supplv&Injection Wells:
Also submit one copy of this form within 30 daysofcompletion 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