GW1-2021-06453_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
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 118 ft' 150 ft' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER! THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. fr. in.
Company Name 16.INNER CASING OR.. BING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. rr, in.
Lisl all applicable irell perntil.s(i.e.Coun(v,State,Variance,/mjec•lion,etc.)
ft. ft tin•
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS f11.ATERIAL
in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrl ation ft. ft.
Non-Water Supply Well: ft. ft.
lZ Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM rt. TO ft. MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hardness,soil/ruck type,grain siu,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. R.
4.Date Well 12/22-20 MW-65Ds)Completed: Well ID# rt. ft. ,c'
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable) \
14226 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,
y ty,and Zip 21.REMARKS � a�
Mecklenburg 4660296960/2104102 Open rock hole
County Parcel Identification No.(PIN)
51h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.412748 N -80.803857 N,
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this ornt,I herehv ceru v that,the well.+' tray were conrtrucled ill accordance
I I f) ( )
with 15A NCAC 02U.0100 or 15A NCAC 02C.0200 Well('uu.rtructiva,4lundnrds and Ural it
7.Is this a repair to an existing well: ❑Yes or ElNo copy Q/'this record has keen provided to the we//owner.
I/this is a repair,lilt an known well construclion in/brntalion and erplain lire nature of the
repair under:2I remarks seclion or on the hack q/'ihis forte. 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.
l,'ur multiple injec•lion or non-wnler supply wells ONLY with Ute sane construction.You can
submit one%ern. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nudliple wells list all dept/tx ifd//ferent(example-3 a200'and 2«100') construction to the following:
10.Static water level below top of casing: 118 (ft,) Division of Water Resources,Information Processing Unit,
4 water level is above 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 form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
8 1/4 HSA 8 2'spoons;10 518 HSA&4'PVC casing 8 6 7/8 Air HAmmef
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
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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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Forn1 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013