GW1-2021-02733_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
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NC Well Contractor Certification Number 15.OUTER CASING for rnulfi-cased wells TOR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. rt. in.
Company Name 16.INNER CASING OR TUBING eothetrotat closed-loo
FROM I TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 32 ft. 4 in- SCh40 PVC
list all applicable melt permits(i.e.Cournw,Slate,Variance.,lnjecitorr,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 82 ft. 57 ft. 4 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
❑Irrigation 0 ft 5.5 ft- Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recoven-
5.5 ft- 7.5 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 7.5 ft- 45 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage 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,girain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 3-1 1-21 Well ID# RW-60
ft. ft. ?`
5a.Well Location: s
ft. ft.
Colonial Pipeline Company ft. ft. MAY 14 201
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft
Physical Address,City,and Zip P ti
21.REMARKS
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one tat/long is sufficient)
35.415511 N -80.806491 W '� Z
Signature of a itied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jorm,1 herebv cerii/y that the we//(s)was(were)constructed in accordance
with 1.5A NC'A'02C.0100 or 15A NCA'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZINo copy of this record has been prorided to the well owner.
tf this is a repair,Jill out known well construciton in/brnnation and explain the nature of the
repair under 21 remarkv section or on the back q/this Jorm. 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.
(or multiple injection or non-water.supply wells ONLY with the same construction.you can
submit oneJbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 57 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l-'or multiple we/A list all depths#ch#erent(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,
t barer/ere/is above casing,ase"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA 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,rotor),.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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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