GW1-2021-06443_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
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I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION!
Well Contractor Name
ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number ' 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO D1.4METERl. '1'H ICKNESS MATERIAL
Parratt-Wolff, Inc. ft. f, !in:
Company Name 16.INNER CASING OR TUBING erithermal closed-loop
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: 0 t; 30 ft- 4 ;in' SCh40 pvc
Lisial/applic•ab/e wet/perniils(i.e.County.A'tale,Variance,hyeetion,etc,.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ISLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft' 50 ft. 4 '"' .010 sch40 Pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 25 ft- Portland'Cem Tremie
Non-Water Supply Well:
10Monitoring ❑Recovery 25 ft- 27.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
27.5 a• 50 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suithocktype,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-1 3-21 Well ID# RW-49 0 `
5a.Well location:
Colonial Pipeline Company ft. ft. 20
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft• ri c•1�7iZi�
14108 Huntersville-Concord Road, Huntersville, NC 28078 , , ��^w `
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Physical Address,City,and Zip -
21.REMARKS 3 t
Mecklenburg 4660199946/1921203 No cover
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)
Cl
35.413080 N -80.805753 N; ,�� 0
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hy signing This form, 1 herehv certi/y that the well(sJ was(urre)c<mslrucled in accordance
irilh 15A NCA'02C'.0100 or 15A NCA'02C.0200 Well Cunstrucliun J7unrtards and that u
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the!well ouvner.
If this is a repair,fill out known well construction wilbrnnation and explain the nolare of
repair under z21 remarks section or on the back of'this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessan'.
bor nmlliple injeclion or non-water supply wells ON/.Y wish die same construction,Yon can
submit one forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 24a. For All Wells: Submit this form within 30 days of completion of well
bor mulliple welts list al/depths tf di/Jerenl texaniple-3 r/200'and 2 n 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
if ivaler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: 19 addition to sending the form to the address in
6 5/8 with 2" split spoons 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.) i
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 m 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'Environnient and Natural Resources-Division of Water Resources Revised August 2013