GW1-2021-06452_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD Pot Internal Use ONLY:
This fiwtn can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Namc
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAM ETFR�: THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETERI THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 17 ft. 2 'In• sch40 pvc
Li.+'i all applicable troll pennies(i.e.County.,Gale,Variance,injection,etc.)
ft. ft.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER eSLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 ft. 37 ft. 2 1n .010 sch40 pvc
❑Geothermal(1leating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMEN'1'MF.THOD&AMOUNT
❑Irri ration 0 12 ft. Portland;Cem Tremie
Non-Water Supply Well:
❑+Monitoring ❑Recovery 12 rt. 18 fr. Bentonite Chil Tremie
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
18 fr• 37 fr• #1 Sand Tremie
❑Aquifer Test ❑Slonnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑'I racer FROM TO DESCRIPTION culur,hardness,soil/ruck type,grai.size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
< w asr
3/3/21 M W-81
4.Date Well(s)Completed: Well ID#
fr. ft.
5a.Well Location: ft. ft. C
Colonial Pipeline Company ft. ft. 7tocts��
Facility/Owner Name Facility II14(ifapplicable) ft. ft. J.+� '
13900 Huntersville-Concord Road, Huntersville, NC 28078 �ilrt. rt.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4660193695/1921204 8°Flush Cover
County Parcel Identification No.(PIN) 2x2 pad
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one ladlong is sufficient)
35.411672 N -80.806653 w; • f a `
Sig tore ol'Certitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv signing dais./brio, 1 herehr c•erlifiy thin thetroll(+)u•us(were)cunsnrtcled in accordance
With 15A NCAC 02C.0100 or 15A N(•A('QC.0200 H'e1/('wla'intciiun.17undards and thin a
7.Is this a repair to an existing well: ❑\'es or ElNo copi,of of is rec•ard has been prorided to the Ire//corner.
l/this is a repair,,lill out known a•e/l construction inlhrmalion and explain the nature of the
repair under=21 remarks.reckon or on the hack of this lhrtn. 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 if necessary.
hor multiple injection or non-u aler supply wells ONLY with the same construction,You can
suhmit one%arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 24a. For All Wells: Submit this form within 30 days of completion of well
hor nudniple we//.r lisp all depths it dilferent(example-3 t,200'and 2@/00') construction to the followmg:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above ea.+inl;,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLI': fn addition to sending the form to the address in
8 1/4 HSA& 2" SpOOnS 24aabove, also submit a copy of this florin 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 ONLI': 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gym) Method of test:
24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form within 30 daysofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form CiW-I Noah Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013