GW1-2021-06455_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used I'm single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 ft. 50 f[. i Wet
2973 ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: 0 ft' 35 ft. 2 in. sch40 PVC
List all applicable ire//permits(i.e.Comor,Stale, Variance,injection,elc)
ft. ft.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER iSLO`r SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 f3. 50 ft. 2 1O' .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 IIIETHOD&AMOUNT
❑Irri ation 0 ft' 31 ft. Portland tern Tremie
Non-Water Supply Well:
IZ]Monitoring ❑Recover)
31 ft. 33 fr. Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemedialion 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 33 ft, 50 ft. #1 Sand Tremie
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hairiness,suil/i'nck lypi,,gnain size,etc.
❑Crenthennal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
rr. fr.
4.Date Well(s)Completed: 12-23-20 Well ID4 MW-68
5a.Well Location: ft. fr.
Colonial Pipeline Company
Facility/Owner Name Facility Ing(if applicable) ft. ft. b
14130 Huntersville-Concord Road, Huntersville, NC 28078 11
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 4661202203/1921233 _ �t 316
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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)
35.413056 N -80.805275 W V-0,1AA
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary Hv signing rhis tornt, l herehv c•erti&that the irel/(s)ira.s(here)consirricied in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well('utsa uclian,1Yutdar<ls and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo cow oJthis record has been provided to the ire/1 umller.
If this is a repair,Jill trill knoirn well construction information and explain the nature of the
repair under-21 remarks sec lion or on the hack gJ lhi.s.larn. 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-uwter.snpply hells ONLY with the saute construction,yori can
sthmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mtlliple ire//.s list all depths ijdiJJerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 37 (ft.) Division of Water Resources,Information Processing Unit,
I/water level is above casing,rise" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: Iti addition to sending the form to the address in
8 1/4 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceti ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 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.
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Form GW-I North Carolina Department of'Environnieni and Natural Resources-Division of Water Resources Revised August 2013