GW1-2021-05616_Well Construction - GW1_20211015

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 I DESCRIPTION
Well Contractor Name ft. ft.
2973 tt. ft.
NC Well Contractor Certification Number IS.OUTER CASING formWli-cased wells OR LINER if a 7icable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft• 4 '"' SCh40 pvc
List all applicable hell permits(i.e.County,State, Variance,bjection,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 5 rr. 40 tt. 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL CM PLACEMENT M ETHOD&AMOUNT
❑irrigation 0 rr. 2 1" Portland Cem Tremie
Non-Water Supply Well:
2 ft. 4 rr. gentonite Chil Tremie
OMonitoring ❑Recovero
Injection Well:
it. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 ft41 fit- #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(ex lain under#21 Remarks) ft. ft.
5-6-21 RW-65 ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. 2021
r
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft. ri '�('G::.3f•�1it4.) t.tnt`
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City;and Zip 21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one[at/long is sufficient/
35.415686 N -80.805519 W (o Z(
Signature of Certified Well Contrac or Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this/hrm, 1 herebv certifi,that the we//(s)was(were)constructed in accordance
With l JA NC•AC 01C.010C1 or 15A NCAC 01C.0100 Well Construction Standards anti that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
//'this is a repair.Jill out known well construction inlorntation and explain the nature olthe
repair under=21 remarks 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 41 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple it ells list all depths i/'di#ereni(example-3@100'and 1C 1001 construction to the following:
10.Static water level below top of casing: None (ft l 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 Infection Wells ONLY: In addition to sending the form to the address in
SpOOnS 24a above, also submit a copy of this form within 30 days of completion of well
10 5/8 HSA and 2
12.Well construction method: " construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Clenter,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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013