GW1-2021-06438_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
f
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 23.5 rl' 37 ft Wet
2973
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. fr. ;in.
Company Name 16,INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 17 ft. 2 i" SCh40 PVC
List all applicable irell permas(i.e.County Rate.Variance,hyec•lion,etc.)
ft. I rt. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 17 ft' 37 ft' 2 in. .010 sch40 IPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT DIE'1'IIOD&AMOLJN'I'
❑li-ri ation 0 If. 10 ft- Portland Cem Tremie
Non-Water Supply Well:
10 rf• 15 rf• Bentonite Chi Tremie
@Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOII
rf•
❑Aquifer Test ❑Stormwa[er Drainage 15 ft' 37 #1 Sand Tremie
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑'tracer FROM TO DESCRIPTION .0in-,hardness,suil/lnck type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 3/2/21 M W-80 ft. f r•s)Completed: Well ID# ft. rt.
r ;a:5a.Well location:
Colonial Pipeline Company
Facility/Owner Name Facility IDk(ifapplicable) ft. ft. .-
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip - '-Fvr�,� Lr
21.REMARKS P R A'� n
Mecklenburg 4660193695/1921204 4"Procover
County Parcel Identification No.(PIN) 2'X2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one hut/long is sufficient)
35.412182 N, -80.806945 N,
SignatT ure ot'Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this Jara y c•, 1 hereberg#,that the well(s)trus(were)e'anslrmled in accordance
with 15A NCA'02C.0100 or 15A NCAC 02C.0200 Well Consm'ttclion.Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy q/this record has been provided to the well owner.
l/this a a repair,hill ant knoll a well construction hilbrinalion and explain the nature of the
repair under v21 remarks section or on the back oJYhis/arm. 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 it'necessary.
Par nuhiple injection or non-water supply wells ONLY with the same construction,you can
stthnil one loran. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Par nalliple wells list all depths i/'dthterea(example-3 o 200'and 2@100') construction to the following:
10.Static water level below top of easing: 23.5 (ft•) Division of Water Resources,Information Processing Unit,
0 water level is above castag use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA& 2" spoons construction
above, also submit a copy of this form 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
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection�Wells:
Also submit one copy of this form within 30 days ofconlpletionof
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water ReIsources Revised August 2013