GW1-2021-07201_Well Construction - GW1_20211006

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple swells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER T THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. f. I in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 tt. 32 5 ft' 4 "' 1 Sch40 I PVC
List all applicable uvell permits(i.e.County.State,Variance,Injection.etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 32.5 IL 47.5 It' 4 '"' .010 Sch40 pvC
❑Geothermal(Heating/Conlin Supply) ❑Residential Water Supply(sin(single) f. R. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft' 28.5 ft- Portland Cem Tremie
Non-Water Supply Well:
28.5 rr• 30.5 It Bentonite Chi Tremie
ZMonitoring ❑Recoven
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
30.5 ft• 47.5 ft• #1'Sand Tremie
❑Aquifer Test ❑S[ormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 8-6-21 Well ID# RW-70
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company f. ft. 2
Facility/Owner Name Facility ID#(if applicable) ft. ft. UKI
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft. t�pce , Von
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:
(ifwell field one lat/long is sufficient)
35.414503 N -80.805230 N; A ju�
S gndture of'Cenified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form, I herebv c•erti(v that the u•ell(s) was 6vere)constructed in accordance
with 15A NCAC 02C.010t1 or 15A NCAC 02C.0200 Well Conatruchon Standards and drat a
7.Is this a repair to an existing well: ❑Yes or ONo copy of dnis record has been provided io the well ouder.
I/'this is a repair,Jill ozu known well c•onsirtction information and explain the nalure q/the
repair under 21 remarks.section or on the back of this farm. 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.
For multiple injection or non-Crater supply wells ONLY u•hh the same construction.von can
submit one fornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 47.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mnhiple zrells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If'maier level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA tat 2" SpOOnS 24aabove, also submit a copy of this form ,Aithin 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) iI
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,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 days ofcompletionof
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 Environment and Natural Resources-Division of Water Resources Revised August 2013
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