GW1-2021-02724_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 32 ft. 36.5 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 7icable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 16 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.Countr.State, Variance.Injection,etc.) ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft. 36.5 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 9 fl. Portland Cem Tremie
Non-Water Supply Well:
Z Monitoring ❑Recovery
9 ft. 11 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicabit
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 11 ft- 36.5 "' #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if:necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gritin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 3/6/21 MW-84 ft. ft.
Completed: Well[D# ft. ft. RECE1 D
5a.Well Location: R. ft.
Colonial Pipeline Company ft ft r AY 14 1
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft, t� -- g Oni1
Physical Address,City,and Zip L�WR Section
21.REMARKS
Mecklenburg 8"Flushmount
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)
35.413196 N -80.807938 W
Signalure of Certified Well Contractor Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary Hv signing this/nrin,1 hereby certify that the we/1(v)vas(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oj7his record has been provided is the we//ovner.
if this is a repair,jilt out known well construction information and explain the nature of the
repair under-21 remarkv section or on the back ofthis/arm. 23.Site diagram or additional well details:
You may use the back of this page!to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-waler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36.5 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
hor nuduple wells list all depths if difJ rent(example-3 a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
//water level is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: 'In addition to sending the form to the address in
10 5/8 HSA 8 2" spoons construction
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,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground 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 the county health department of the county where
consu ucted.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August'-013
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