GW1-2021-05618_Well Construction - GW1_20211015

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 muhi-eased.wells OR LINER if a lieable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING g edthermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 16 ft- 4 in- SCh40 pvC
List all applicable well permits(i.e.County,State, Parlance,Injection,etc.)
ft. ft. '. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS17E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 ft- 56 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 EMPLACEMENTMETHOD&AMOUNT
❑irri ation 0 ft- 12 1 Portland Cem Tremie
Non-Water Supply Well:
12 ft 14 ft Bentonite Chi Tremie
(EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
14 ft 56 ft- #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 lcolor.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
" F k
4.Date Wells 7-23-21 RW-72 ft. ft.
Completed: Well ID# P
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft If.P ��li�,t
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft ft. = p�,V; ;,c ;u,
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[at/long is sufficient)
35.415738 N -80.805649 W g a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary ey.signing this firm,1 herebv certify that the well(s)was(were)constructed in accordance
with I JA NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construcuon Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
4 this is a repair,fill out known well construction information and explain the native g(the
repair under=11 remarks section or al the back g/'ihis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nmltiple injection or non-water supply wells ONLY with the same construction,you can
submit one,)arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 56 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fir nnthiple wells list all depths lfdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
4 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 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(gpm) Method of test: lac.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 ot'Environment and Natural Resources-Division of Water Resources Revised August 201?