GW1-2021-06441_Well Construction - GW1_20211022

i
WELL CONSTRUCTION RECORD !
For Internal Use ONLY: �
This form can be used for single or multiple wells i
I.Well Contractor Information: i
Kevin White 14.WATER ZONES
FROM I I'D DESCRIPTION'
Well Contractor Name 57 165 ft Wet
2973
I
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased wells OR LINER ifs cable
FROM TO DIAMETERk liMATE THICKNESS RIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETERI THICKNESS I MATERIAL
2.Well Construction Permit#: 0 rr. 35 ft. 4 in• SCh40 PVC
List all applicable well permits(i.e.Cotonp,Sate.Variance,Injection,ere.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 ft' 65 ft. 4 in. .010 SCh40 PVC
f. f. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
❑irri ation 0 ft' 31 ft- Portland Cem Tremie
Non-Water Supply Well:
E Monitoring ❑Recovery
31 ft. 33 ft- Bentonite Chi Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MATERIAL; EMPI, CEMENTMETHOD
ft ft
❑Aquifer Test ❑Storm 33 65 #1 Sand Tremie
water Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothernnal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culor,hardness,soil/ruck type, min size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
rt. fr.
4.Date Well 12-23-20 RW-51s)Completed: Well ID# ,
t j
52.Well Location: R. R. " '�.:�
Colonial Pipeline Company fr. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
14108 Huntersville-Concord Road, Huntersville, NC 28078 rt• t1tZ(
Physical Address,City,and Zip
Mecklenburg 4660199946/1921203 21.REMARKS
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)
35.413311 N -80.805491 N;
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
BY signing(hi.r,limnt,1 herehv cer(i/v that(!re troll(+)trus(mere)cuns'truc(ed in uccurdunce
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well('uns'Irncliun S'landurds'and that a
7.Is this a repair to an existing well: ❑l'es or ZlNo copy aJ'this record has been provided to the bell owner.
4this is a repair,Jill oat known troll construction in1brnta(ion and explain the nature of 1he
repair under=21 reinarkv.section or an(he hack o/7hi.rJbrin. 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'necessan'.
h'or multiple injection or non-water supply tre2v ON1.Y with the same construction,you can
submit one Jorin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nw hip/e me//.v fist a//depths i/di/ierent(example.3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 57 (ft•) Division of Water Resources,information Processing Unit,
//hater lerel is above caring,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
I L Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA 24a above, also submit a copy of this!form within 30 days of completion of well
We
ll ell construction method: construction to tine 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletionof
13h.Disinfection type: Amount: well construction to the county health;department of the county where
constructed.
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Form GW-I Notth Carolina Department of'Ero,nonment and Natural Resources—Division of Water Resources Revised August 2013