GW1-2021-07729_Well Construction - GW1_20211116

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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 65 ft' 198 ft. Wet
2973 ft. ft.
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. ft. in.
Company Name 'Y6.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETERS THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well perntit.s(i.e.Cougi,.elate,Variance,htjeelion,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well:
ElMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PAC K(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑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 color,haidness,soilhoekt ie,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 2/27/21 s)Completed: Well ID# MW-14D
5a.Well Location: ft. ft.
Colonial Pipeline Company rt. rt. V 1
2071
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
REMARKS 1r-r,1;iF,3i-Tlf7g1 Y if?ts,t�,;i'all�tr:' ,�+,•
Mecklenburg Open hole
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)
35.412585 N -80.805547
Signature ofCerti ied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 herehY certi/y that the.,rell(s)irar(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cunstructiun Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No cope ofthis record has been prorided to the fire//mi-ner.
ifthi.s is a repair,Jill out known we/1 con.siruclion in/orntation and explain the nature o/'the
repair under 41 rentarks.vection or on the hack o/'Ihis{brill. 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 nndliple injection or non-iraler supply ire/tv ONLY with the Kane construction,you call
suhnin one.lornt SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nuthiple ire//.s list al/depths#dihtereni(example-J«200'and 2@100') construction to the following:
10.Static water level below top of casing: 65 (ft-) Division of Water Resources,Information Processing Unit,
I/'crater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: hi'addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
Sac pvc casing & 4" Air Hammer
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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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.
Form GW-I North Carolina Department of Enviromnent and Natural Resources—Division of Water Resources Revised August 2013