GW1-2021-07197_Well Construction - GW1_20211006

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 ft. ft.
2973 ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a
FROM TO DIAMETER' THICKNESS licable MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 12 ft. 4 in. SCh40 pvC
Li.sl all applicable well permits(t.e.CountY.Stale, Variance,Inlec•lion,etc'.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 12 ft. 52 ft. 4 in.' .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
❑Irrigation 0 rt. 8 e. Portland Cem Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
8 rr• 10 ft- Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 10 ft' 52 ft- #1 Sand Tremie
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Remr) ❑Other(ex lain under#21 Remarks) ft. R. Ir
ft. ft.
4.Date Well 8-4-21 RW-75s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. O v�
Colonial Pipeline Company ft. ft. s
ce.
Facility/Owner Name Facility ID#/(ifapplicable)
ft. ft. .0, Sg
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. R. \r$45 ` Q J
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one[at/long is sufficient) /D
35.415738 N -80.806512 W X,.Ie-t� AT g-3i. Zf
S gnt ature of'Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
HY.signing this./brit,!hereby ceni(v that the u•ell(s) was(lucre)constructedin accordance
frith 15A iWAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O No copy of this record has been provided to the is-ell owner.
this is a repair,fill out knou it well construction information and explain the nature o0he
repair under all remarks section or on the back at this form. 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 if necessarx
/or multiple itsfection or non-traier supply ire/1s ONLY frith the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 52 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iI differenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft•) Division of Water Resources,Information Processing Unit,
IJ*nvater level it above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA 8t 2" spoons24aabove, also submit a copy of'this fort 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
(gP ) 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013