GW1-2021-06448_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple Hells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 32 fr• 36.5 tr' I wet
2973
NC Well Contractor Cenification Number 15.OUTER CASING(for multi-cased wills)OR LINER ifa Iicable
FROM TO DIAMETER THICKNESS MA•TER1A1.
Parratt-Wolff, Inc. ft. ft.
Company Name 76.INNER CASING OR TURING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 16 R• 2 i" SCh40 PVC
list all applicable well permits(i.e.r•aunnt Slate.Variance,injection,etc.)
rt. rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16 fL 36.5 ft' 2 in. ' .010 SCh40 PVC
ft. r. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑trri ation 0 rt. 9 ft. POrtlandCem Tremie
Non-Water Supply Well: '
OMonitoring ❑Recovery 9 fr' 11 fr' Bentonite Chil Tremie
Injection Well: ft. fr.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOII
fr• fr•
❑Aquifer Test ❑Stonnwater Drainage 11 36.5 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/ruck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
tr^
.,m
4.Date Wells)Com 3/6/21 pleted: Well ID# MW-84 I
ft. ft.
5a.Well Location: fr. ft. Cj
Colonial Pipeline Company
Facility/Owner Name FacilityIDt (ifaPPIicable)
ft. fr. ,� 'fit i�' t' s J�GL•Otl
13900 Huntersville-Concord Road, Huntersville, NC 28078 WE
rr. rt.
Physical Address,City,and Zip �-
21.REMARKS
Mecklenburg 4660193695/1921204 8"Fiushmount
County Parcel Identification No.(PIN) 2�x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.413196 N -80.807938
Signature of Certified Well Contactor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Br signing This form, 1 herehv c•er6&dnat;the well(s)eras(were)constructed ill accordance
u•tdt 15A Nt•A'02C.r 100 or 15A Nt•A'02C.0200 Well Construction Standards and thin u
7.Is this a repair to an existing well: ❑Yes or EJNo copy at this record has been provided to the well owner.
if this is a repair.till out known ire/l construction information and explain the nature ojlhe
repair under<,2l remarks section or on late hack at''I/ri.r form. 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 nlay also attach additional pages if necessary.
hbr mu/liple injection or non-water supply wells ONLY with the sante construction,you can
subunit onelorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36.5 (ft.) 24a. For All Wells: Submit this t'orm within 30 days of completion of well
Vor nwhiple wells list all deplhs trdtjjerenn(example-3 a,200'and 2@100') construction to the following:
10.Static water level below top of casing: 32 (ft•) Division of Water Resources,Information Processing Unit,
//'wafer lerel is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA & 2" spoons24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
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(i.e.auger,rotary,cable,direct push,eta)
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 i within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of'Environmetn and Natural Resources-Division of Water Resources Revised August 2013