GW1-2021-06253_Well Construction - GW1_20211022

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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 30 ft. 48 ft. I Wet
2973 ft. f.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAM ETERi THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. !in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 118 ft. 2 in• SCh40 PVC
Lill all applicable well pernut.r(i.e.Coun(V,Sinle,Variance,Injection,ele.)
ft. I in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 ft' 38 ft' 2 in. 010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ff. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 r' 13 ft. Portland`Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
13 ft. 16 r'• Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquiter Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
r' rr•
❑ 16 38 #1 Sand Tremie
Aquifer Test ❑Stormwater Drainage R. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hatduess,suil/rucktype, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
2/25/21 MW-79 ft. ft. t ,�
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: et. If. 11 C T v 2021
Colonial Pipeline Company ft. ft.
QS!,inq Uili)
Facility/Owner Name Facility IDN(if applicable) f tivr i r c' "
ft. ft. � �vO�Q�
13900 Huntersville-Concord Road, Huntersville, NC 28078 rt. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204 4"Stick up cover
Comity Parcel Identification No,(PIN) 21x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.412541 N -80.807348 N, 3- (S Z l
Signature ofCenitte Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary 8 h / �. (�
HV�+'i nitr�this orvu, l herehV ecru V dual file well.r trax trerc constructed in accordance
trilh 15A NCAC 02C.l1100 or 15A NCAC 02C.0200 Well Construction Slandards and Thal a
7.Is this a repair to an existing well: ❑N'es or ONo copy of this record has been provided to the well corner.
y afi s is a repair,fill oal known trell construction inlnrntalion and explain the nature of the
repair under=21 retnarks.+eenoo or at;file hack o/'this farm. 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.
hor nmhiple hyeelion or nun-+rater supply+reps ONLY with the sane construction,you can
suhtnil onelortn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 38 24a. For All Wells: Submit this form within 30 days of completion of well
/•or nu/liple wells list al/depths i/'dtl/ereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
l/hater level is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the furor to the address in
8 1/4 HSA & 2" split spoons 24aabove, also submit a copy of this torn within 30 days of completion of well
12.Well construction method: construction to the tollowing:
(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:
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Also submit one copy of this form within 30 daysofconipletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form r W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013