GW1-2021-02727_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
ft. ft.
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-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 ebthermal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 16 ft- 2 in. sch40 pvc
List all upplicable well permits(i.e.Couatr.Slate,Variance,Injection,etc-.)
ft. f[, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 "' 46 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial El Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft 7.5 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recover\ 7.5 ft 10 ft Bentonite Chil Tremie
Injection Well: fr. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 10 ft. 46 ft. #1;Sand Tremie
El 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 leolor,hardness,soil/rack type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
3/14/21 MW-86 ft. ft. s�
4.Date Well(s)Completed: Well lD# fr. ft. t
5a.Well Location: ft. ft.
Colonial Pipeline Company rr. ft.
Facility/Owner Name Facility ID#(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. ";�;�rccess 9 11'
R. ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN) 2 x2 pad and cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient)
35.412011 N -80.805826 W
Signature of Certified Well Contractor • Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing Ihi.c form, I herehv certifi+that the rrell(s) Was(were)constructed in accordance
Willi 15A NUAC 02C.0100 or 15A NCACi 02C.020t1 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gfafus record has been provided to the well owner.
Ifilvis is a repair,fill out known Well construction information and explain the nature of the
repair under=21 remarkv.sec•tion or on the hack gflhis loan. 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 multiple injection or non-water supply wells ONLY wah the same consrruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
knr multiple wells list al/depths if di#j rent(erample-3 ct 200'and 2 a 100') Construction to the following:
10.Static water level below top of casing: (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 Iniection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA& 2" SpOOnS 24aabove. also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the followima
(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 ofcompletion of
13b.Disinfection type: Amount: well construction to the 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