GW1-2021-06439_Well Construction - GW1_20211022

i
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• 33 ft. I Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if on
licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft, ft. in.
Company Name 16.INNER CASING OR TUBING fecothermal closed-loci
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 13 rr. 4 'in. sch40 PVC
list all applicable+cell perniit.c(i.e.County,,Smle,Variance,hyeelion,ete.)
ft. ft. i in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLO'19 SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft' 33 ft. 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 9 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
9 ft. 11 ft, Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
11 ft• 33 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culor,barduess,st,ith—k ty1m,grAnsire,etc.
❑Geothermal(Healing/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft' ft'
4.Date Well 1-19-21 s)Completed: Well ID# RW-53
5a.Well Location:
Colonial Pipeline Company rt. ft. CT4011
Facility/Owner Name Facility ID#(if applicable)
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 ladlong is sufficient)
35.413240 N -80.806108
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary x ! / h, (1
ev si milt�Ihi.r arm, 1 herehv cerii deal the moll.r uvs here constructed in accordance
with I5A N'AC 02C.0100 or 15A NCAC 02C.0200 Well Constrmc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gJ'this record has been provided to the well owner.
4 this is a repair,Jill out known well construction in/irrmation and explain the nalure of the
repair under-21 rentarks.section or on the hack o/ihi.s Jnrnt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
l-or multiple injection or non-water supply wells ONLY with the same construction,you can
.suhnni one/arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 33 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
/•br nwhiple wells list all deplhs q clitlerent(example-9@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lJ'water level is above easing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection 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 Centel,Raleigh,NC 27699-1636
13a.Yield In Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days ofcompletionof
13b.Disinfection type: Amount: well construction to the county health`department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013