GW1-2021-05617_Well Construction - GW1_20211015

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 26 f` 45 f`' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft. 4 in. sch40 PVC
List all applicable well permits(i.e.Counw.Slate, Variance.Injection,etc•.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft. 45 f` 4 in- .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft. 6 ft- Portland Cem Tremie
Non-Water Supply Well:
6 fr. g ft- Bentonite Chi Tremie
ZMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 f`• 45 f`• #1 Sand Tremie
❑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 color•hardness,soil/rock type.grain size,etc.
❑Geothermal(Heating/Cool ing Return) ❑Other(explain under 421 Remarks)
4.Date Well 5-6-21 RW-66s)Completed: Well 1D# ft. ft. Ff o 9
5a.Well Location: R. a. 'h`•'Y�y yam'' -
Colonial Pipeline Company ft. ft
0
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NIC 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:
(ifwell field one lat/long is sufficient) /\
35.415686 N -80.805519 N; �T
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary ey signing this form,I herebv cerli i,that the Ire/l(s)tras(mere)constructed in accordance
with 15A NCAC IIIC.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 q(this record has been provided to the well owner.
I/this is a repair.fill out known well construction inlhrmation and explain the nature ol'the
repair under 21 remarks section or on the back g11his lhrm. 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 nmhiple injection or non-(rater supply bells ONLY with the same construction,ynn c•an
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjereni(example-3@200'and 1@/00') construction to the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
I/(rater 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 and 2 24a above, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: 11 SpOOf1S 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 Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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