GW1-2021-02722_Well Construction - GW1_20210514

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
f[. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 14 ft. 2 '" SCh40 PVC
List all upplicable nv//permits(i.e.County.Slate, I'ariance,Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14 ft' 39 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 ft. 9 a, Portland Cem Tremie
Non-Water Supply Well:
17IMonitorina ❑Recoven- 9 ft. 12 ft- Bentonite Chil Tremie
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a ticable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 12 ft. 37 ft. #1�Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach 2dditionid sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft. d.
4.Date Well(s)Completed: 3/2/21 Well ID# MW-82 ft. R t 9'-. rf
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft,
Facility/Owner Name Facility ID#(ifapplicable) F
ft. ft. Information 17rC;;e$$ln C1i1�.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. v vrm
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 8"Flush 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 lat/long is sufficient) / \
35.411508 N -80.806448 W
Signs ire of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this farm, I hereby certi that the tre/1(s)was(were)constructed in accordance
trlth 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well('onstruction Slaiularcls and that a
7.Is this a repair to an existing well: ❑Fes or E]No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and erphvn the nature of the
repair tinder c21 remarks section or on the back(ifilu.sJorm. 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 necessary.
bor multiple injection or non-truer supply me Rs ONLY ivuh the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple tre/A list all depths ifdi/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1/hater 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 8t 2" spoons24aabove, also submit a copy of,this form Mthin 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,lUnderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: lac.For Water Supply&Injection Wells:
Also submit one copy of this fond within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Font GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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