GW1-2021-02726_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR;LINER if a rrcable
FROM TO DIAMETER THICKNESSI MATERIAL
Parratt-Wolff, Inc. ft. It. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 40 ft. 2 in. SCh40 PVC
List all applicable well permits(i.e.Counrr,Stale, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft. 70 ft. 2 in.; .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. R, in.l
❑Industrial/Com mere ial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑lrri ation 0 ft. 36 ft- Portland Cem Tremie
Non-Water Supply Well:
36 rr. 38 rr. gentonite Chi Tremie
OManitoring ❑Recover`
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remedia[ion 19.SAND/GRAVEL PACK if applicable)
[I Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
38 ft. 70 ft. #1'Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ,
❑Experimental Technology ❑Subsidence Control ft. fr.
20.DRILLING LOG attach additional sheets if;necesss
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colon hardness,soil/rock type,gimin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 2-5-21 HCW-23 ft. ft.
RGEs)Completed: Well ID# ft. rr. E ep 6
5a.Well Location: ft. ft. MAY
Colonial Pipeline Company ft. ft. MA l
Facility/Owner Name Facility ID#(if applicable) ft. ft. I I`I t'' t nn ProcessinJ, Ur 1`•
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient
35.413866 N -80.804286 W.
SienOure ofCertitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hv.signing this.lorm, I herebY ceriJi,that the well(s)tras(here)constructed in accordance
with IJA NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy ol'this record has been provided to the well owner.
lj'this is a repair,Jill out known well construction inJbrmation and explain the nature at the
repair under=2I remarks section or mh the back of this jbrm. 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
l-or multiple injection or non-water supply trells ONLY with the same construction.you can
submit oneJbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor multiple wells list all depths i/'dijferenn(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
Ijlrater level 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
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 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 font within 30 days of completion 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