GW1-2021-01325_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD „r I,nernit l 0\1)
Tlu..Gam can be used for smele m mul ople lel is
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPf10%
well Contractor\.me fit. ft.
2973 n. ft.
V( well Contractor C'emflru,on Aumber 15.011TER CASING(fir�dKtrd weY OR LINER Y W
FAUN TO DIAMETER THICF:NENN I MATERIAL
Parratt-Wolff, Inc. fit. ft.
Gm,.."\ame 16.INNER CASING OR TUBING
FROM TO DOMIF ER THICKNESS AI ATERI4L
2.Well Construction Permit#: 0 ft' 25.5 f'' 2 to.
Seh40 plc
Lnr all applrieMe,roll p rnrn,n o ,'nur,v.Stan•. I't...... -/ale.unn..ar, t
D. R.
3.Well Ise(check well use): 17.SCREEN
W'aIce Supply Well: FROM I 1(1 I DIAMETER I SLOTSIZE THICKNESS AI.ATEEIAL
❑Agricultural ❑Mumc,pal:Public 25.5 n- 27.5 ft 2 in' .010 SCh40 PVC
-Geothermal illeatin¢'Cooling Suppl%I ❑Res,denual Water Supple(single) D. I ft. t
n.
Olndustnal/C'ommerc,al CResidenual Water Suppk(sharedl IL GROUT
mom TO MATERIAL EMPLACEMENT MEFROO a,AMOUNT
❑hrt afion 0 f`' 20.5 n- Portland Cem Tremie
Son-Water Supple Well:
YMominnne ❑Recover, 20.5 D' 23.5 D. Bentonite Chi Tremie
Injection\\'ell: ft. ft.
❑.Aquifer Recharge ❑Groundwa[er Remed,arm 19.SANQGRAVEL PAYTC
FAON TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Reco%e`)i ❑Salin lv Barrier
23.5 "' 127.5 ft 1 #1 Sand I Tremie
❑Aquifer Test ❑Stormwater Drainage
fit. fit.
❑E\perimental Technoloe, ❑Subs,deme Control 3L DRR.IJNG LOG Iattaeb sdodmisbeebY
❑CreOthemtil(Closed Loop) ❑Tracer FROM TO DESCRIFTIONcaer:homer,,toluork nim,we.er.
❑Oeothermal(Heating/Coolme Return) ❑Other(explain under#'_1 Remarks) fit. ft.
J.Dale Wells)C 12-9-20 AS-05 f` ft.
ompleted: Well ID# ft. B.
n
5a.Well Location: ft. ft.
Colonial Pipeline Company fI ft. MAR
Facda,G,,ner Name N,da%lD=Ufapphcable) ft. ff.
14511 Huntersville-Concord Road, Huntersville, NC 28078 n n
G,e
Pln sical Address,C'iry and lip 21.REMARKS
Mecklenburg No cover
Cnuna Parcel ldenulicauan\t (PIN,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 CCeniBcation:
(it xell Held nne lot Ion,,s sutLacnu
35.412535 80.806399 W
S,maimeuf(enitied well('omracmr Date
6.Is(are)the well(s): W Permanent or ❑Temporary N, .,gmtp rho loan. /h,,hr.r.aq rlmt tin- , ..ild m o..trdmnv
ugh 1J.{,Vf:-f'0 f 111041 ur lid,V(A( 02f 0200 R'ell farsunc um SYamrard.and that u
7.Is this a repair to an existing well: OSSes or ONo a,p,of1his,,ordhmbeenprornkdlatheu0itune,
110m s a rcpn,fill tat kamnr,cell inn.,vuooun irrltrn,uuan anJ erplam the tanvr.J the
rrryur corder ?/rcnmrk+n-.uun nr to,he hark J this/tray. 23.Site diagram or additional well details:
Sou may use the back of this page to provide additional well site details or well
S.Number of wens constructed: 1 constrri details. You mac also attach additional pages if necessar,
4,,muh pie,atria....tr non-,mmr v,pph and/•O.N1..I'rah the same rnnnruninn-„m,ua
Gahm I toe lira, St BMITT:U.INSTC(-TIONS
9.Total well depth below land surface: 27.5 (ft.) 24a. For All Wells: Submit this form within 30 dins of completion of well
Pa,u../ulu,ndrho,didepJf.gJ,/)erem l,ra,ltplr.3,2')0''u,21 100') r'unstRlcuon to the following
In.Static water level below top of casing: unknown (ft) Division of Water Resources,Information Processing I nit,
h nercNerc/u uhnre.mnly.tr., 1617)fail Sees ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONIA In addition to sendmg the torn to the address,n
8 1/4 HSA 24a above. al..) submit a cop%of this torn within 30 da\s of completion of well
12.Well construction method: construction to the tollowme.
1,c immer_ otti cable,due,,push.ere
Division of Water Resources,Underground Injection Control Program,
FOR WATER St PPL\-WELLS ONIA`. 1636 Mail Service(enter,Raleigh,NC'27699-1636
13a.Wield igpm) Method of test: 24c.For Water Soffits& Injection Wells:
-Also submit ,me cop, or this torm within 36 dacsofcumpletum ut
13b.Disinfection type: %mount: "ell construction to the count, health department of the count\ where
cunstructed
I inn O\l-I \aril,(a hnu 1),,nmu I of Lit r,n.,mmn,and♦unual Remora,,-D..snm of M'mer Re.uwccs Re.iced August'_017