GW1-2021-00427_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 36 ft• 38 ft. Wet
2973 ft. 1 ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 1 36 ft. 2 in. Sch40 pvc
list all applicable:rell pernnis(i.e.Counne State. f%ariance,Injection,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 ❑Municipal/Public 36 ft. 38 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 32 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
32 ft• 34 fit- Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 34 ft' 38 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,soilhock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 12-7-20 s)Completed: Well ID#AS-07 ft. ft.
ft. ft.
Sa.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. NV
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
Physical Address,City,and Zip �:`•'-,n^ �'t; '1•v �inrI t l 1
21.REMARKS ` t:'i' moo.-:i;�
Mecklenburg No cover r�
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)
35.412277 �, -80.806163 W. VLF e ,'
Signature ofCertifted Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary BY.signing dni.s Jorm, l hereby cerii(i,that the well(s)was(were)consiructed in accordance
%,nh 15A NCAU 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and ihai a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has been provided In the%tell owner.
If this is a repair,fill mu known it covsir ction information and explain the nature of the
repair under.2/remarks seciion or on the back ofthis Jarm. 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.
Fier nmhlple injection or non-%rater supply wells ONLY wide 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
1-tor mulop/e wells lisi all depths ijdifferen(example-3 a 200'and?@100') construction to the following:
10.Static water level below top of casing: 36 Division of Water Resources,Information Processing Unit,
f/%vaier level is above 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 24a above. also submit a copy of this form within 30 days of completion of well
12.Nell 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 die 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