GW1-2021-05627_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 DESCRIPTION
Well Contractor Name 45 rL 55 fL Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells SS OR LINER if.a licable
FROM TO DIAMETER THICKNE MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft, 35 fr. 4 in. sch40 pvc
List all applicable well perm0s 6.e.(bump,State, 17arianc•e,Injection,etc.) ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 fr' 55 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
❑irrigation 0 rt• 2g 5 13, Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recovery
28.5 fr. 31 fl, 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 El Salinity Barrier 31 rt• 55 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if oecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION lcolor.hardness,soil/rock type.grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 4/23/21 MW-87s)Completed: Well ID#
5a.Well Location: - t
ft. ft.
Colonial Pipeline Company ft. ft.
OCT1 2021
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
ii�x(T b;,nf5ilt
Physical Address,City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN) 2 x2 pad and 6"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field.one lat/long is sufficient)
35.415094 N -80.804553 W !� Z Z,
Signa u-e of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hv signing this Jornt, 1 hereby c•ertifi,that the welly was(,were)constructed in accordance
frith 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy q/1his record has been prorided to the well owner.
l/this is a repair,till out known well c•on.sirtnYion information and explain the nature ol7he
repair under-21 remarks section or on the back of.of isJi)rm. 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.lorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For muhiple we1Ls list all depths iI chlfereni(trample-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 45 (ft.) 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
8 1/4 HSA/10 5/8 HSA/ &2"spoons 24a above, 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
i
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013