GW1-2021-06249_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD I'or Internal Use ONLY: i
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Namc 32 rt. 36 ft.
wet
2973 ft.
NC Well Contractor Certification Number 15.OUTER CASING j 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 fileothermal closed-lootill
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 21 H. 4 i" SCh40 PVC
List all applicable well pernury(i.e.Cotn(v,Stale, Variance,Injection,etc.)
ft.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 21 ft. 36 ft. 4 in. .010 sch40 PVC
ft. ft, in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENTMETHOD&AMOt1NT
❑hri a[ion 0 1t 17 1t Portland,Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recoveryy
17 ft• 19 fr• Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a lieable
I
❑Aquifer Storage and Recovery ❑Salinity Barrierce 19 36 ft. #1 Sand Tremie
EMPLACEMENTMETHOD
FROM TO MATERIAL a•
❑Aquifer Test ❑Stormwar Drainage R. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hardness,suilhocktype, grin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
fr. rr.
4.Date Well(s)Completed: 1-21-21 Well ID# RW-55
5a.Well Location: ft. ft.
Colonial Pipeline Company
p ft.
Facility/Owner Name Facility IDN(ifapplicable)
ft.
14108 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg 4660199946/1921203
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)
35.412659 N -80.806081 N' �.Q/Vl/� ITV pZ. G,
Signature of'Cerfified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv signing This Jbrn4 /herehv certi/iy that the u'e//(+)was(u ere)constructed in accordance
With 15A N'AC 02C.0100 or 15A N'AC 02C.0200 Well('uns't•tucliun JYundards trod Thal a
7.Is this a repair to an existing well: ❑Yes or E]No copy o(this record has been provided to the irel/owner.
/f this is a repair,Jill out known well construction tnlbrmtalion and explain the nature n(the
repair under g21 reunarks.section or on the hack oJ7his/brin. 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.
hnr multiple injection or non-wrier supply welts ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nndliple wells list all depths iflilleretit(example-3@200'and 2«100') construction to the following:
10.Static water level below top of casing_: 32 (ft•) Division of Water Resources,Information Processing Unit,
I(u•ater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA 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
l
m 13a.Yield
(gP ) 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.
i
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013