GW1-2021-06451_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
I.Well Contractor Information: C
Kevin White 74.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name 25 `r• 113 `t' ' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING Tor multi-cased wills OR LINER if a licable
FROM TO DIAM ETER - 't•HICKN ESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 98 ft. 2 in. sch40 pvc
List all applicable hell pernuis,(i.e.Counrv,State,Variance,Mjeeiian,etc)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 98 f' 113 f`' 2 '"' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 89 ft- Portland,Cem Tremie
Non-Water Supply Well:
ElMonitoring ❑Recovery 89 f` 94 fr' Bentonite Chii Tremie
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if.a `licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMI'LACEMENTMETHOD
94 ft 113 rr #1 Sand Tremie
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG,attach additional'sheets if necessary)
❑Geothernial(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,s.0/r.cktype,grairs size,err.
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 7-18-21 Well ID# MW-81 D
ft. ft. sue*•
5a.Well Location:
Colonial Pipeline Company rr• ft. UIjI
Facility/Owner Name Facility ID#(if applicable) ft. ft.
oG1,OC�
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204 8"Flush Cover
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 laUlong is sufficient)
35.411707 N -80.806545 W ` ( � • oZ
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this lornt, 1 hereh'r,certt(i,that the wells) was(were)constructed in accordance
irah 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards laud that it
7.Is this a repair to an existing well: ❑Yes or 9 No copy ulthis record has heen provided to the well owner,
q this is a repair,Jill out known well construction inlorma oon and explain the nature of the
repair under a21 remarks section or on the hark o/7hts Jhrrt. 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 it'necessary.
hor multiple injection or non-wafer supply we/Lc ONLY wilt the same construction,you can
submit one fornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 113 (rt) 24a. For All Wells: Submit this form within 30 days of completion of well
l,'or nndttple wells list ass/depths it dilIrrent(example-3 a 200'cad 2@100') construction to the following:
10.Static water level below top of casing: 25 Division of Water Resources,Information Processing Unit,
If water/ere/is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the tonn to the address in
6 5/8 HSA&2"spoons&6'Air Hammer l4"PVC Casing 24a above, 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 Center,Raleigh,NC 27699-1636
I
13a.Yield m Method of test: 24c.For Water Supply&Injection(Wells:
tKP ) Also submit one copy of this fond 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 Nonlu Carolina Department of'Enviromuent and Natural Resources-Division of Water Resources Revised August 2013