GW1-2021-02719_Well Construction - GW1_20210514

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 35 145 rr' Wet
2973 ft. ft.
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. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 25 ft- 2 in. SCh40 PVC
List all applicable hell pernnac(i.e.Counm.Stale, f'arianc•e,bliec•tion,elc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 rL 50 ft' 2 '"' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rr. 20 ft" Portland Cem Tremie
Non-Water Supply Well:
20 ft- 23 ft Bentonite Chi Tremie
ZMonitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
23 fr 50 ft #1 Sand Tremie
❑Aquifer Test ❑Storm�vater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under 421 Remarks) I ft. ft.
ft" ft"
4.Date Well 2/25/21 MW-78s)Completed: Well ID# ft. ft. •
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. ss g Unit
Facility/Owner Name Facility IDN(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 wt4R Sec�'o
rt. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4"Stick up cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Hat/long is suflicieno
35.412904 N -80.807584 N; � (� 3 , Z / • Z \
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing This./arm, /herehv certi[i,that the i ell(s)was(were)cansir icred in accordance
vilh 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well t onslruction•Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy g/this record has been provided a,the ire//owner.
Y this is a repair,ill out known ivell conviruction inforinalion and erplain the nature o/lhe -
repair under 11 reinarks.section or on rile hack of hors/arin. 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 nlulltple injection or non-iratersupply wells ONLY with the some construction,you call
submit one Ibrnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a" For All Wells: Submit this form within 30 days of completion of well
hor multiple hells list all depths ijdiffereni(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 40 (ft") Division of Water Resources,Information Processing Unit,
l/iraier/erel is above casing,use- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA & 2" split spoons 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection hype: Amount: well construction to the county health department of the county where
constructed.
Fonu GW-I North Carolina Depaitnient of Ern,ironnient and Natural Resources-Division of Water Resources Revised August 2013