GW1-2021-05621_Well Construction - GW1_20211015

i
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 50 ft' 63 ft. Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 43 ft- 2 in' SCh40 PVC
List all applicable a ell permits(i.e.Counn:State,Variance,Injection,etc.) ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 43 ft' 63 ft' 2 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
❑Irri ation 0 ft' 38 ft- Portland Cem Tremie
Non-R'ater Supply Well:
❑Monitoring ❑Recovery 38 fs. 40 it. Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 40 ft• 63 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheers if necessary)`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gmin size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 4/28/21 s)Completed: Well ID# MW-88 ft. ft.
tr. tr.
�r
5a.Well Location: ft. ft.
Colonial Pipeline Company j
P P Y ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) fr ft nn
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
,Physical Address City,
y ry,and Zip 21.REMARKS -^�:e.'"31'.�• ' j-,"�.,._
Mecklenburgt�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field one lat/long is sufficient)
35.415269 N -80.804274 W
Signatw'e of Certified ell Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary BY signing this 1brm,1 herebv cerli(v that the well(s)was(here)constructed itr accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conviruction Standards and that a
7.Is this a repair to an existing well: ❑1 es or E]No copy q/this record has been provided to the well corner.
If this is a repair,fill out known well construction information and explain the nature o0he
repair under=21 remarkv section or on the back of this/brat. 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.
I•br multiple injection or non-irater.supply nve/ls ONLY with the same crmstrvction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 63 24a. For All Wells: Submit this form within 30 days of completion of well
Vor multiple welts list all depihs ill differew(example-3C200'mid 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
I/water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: 'In addition to sending the form to the address in
8 1/4 HSA/ & 2" spoons24aabove, 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: 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 count'where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201_