GW1-2021-07735_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 1
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1.Well Contractor Information:
14.Gary Ellingworth FROM WATER Z ONES DESCRIPTION
Well Contractor Name ft. ft.
3367
NC Well Contractor Certification Number 15.OUTER CASING for Mc Led wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft. i in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rr. 11 rr. 4 '"• SCh40 PVC
List all applicable well permits(i.e.Coun(v,State, f%ariance,Injection,etc-.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 ft- 46 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 I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 7 1 Portland Cem Tremie
Non-Water Supply Well:
7 fr. g ft Bentonite Chil Tremie
OMonitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licible
- FROM TO MATERIAL EMPLACEMENTMETHOD
9 46
❑Aquifer Storage and Recovery ❑Salinity Barrier R. ft.
#1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
IO.DRILLING LOG`attach addition al sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gnin size.etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 10-15-21 s)Completed: Well ID# RW-87 ft. ft.
ft. ft. ,
5a.Well Location: `
1r. rr•
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 7071
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS
Mecklenburg rt�wi l rrtl;i' i ti t.i,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
35.413674 N -80.806968 W. (. `�z
Signature of pitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BT signing this fimn,I herehv certifv that the we//(s)trac(sere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0 No copy ojthis record has been prorided to the well owner.
U'Ihis is a repair,till out known well construction intbrnulion and explain lite nature o0he
repair under.21 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 or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
(or nmhtple injection or non-wafer supply wells ONLY with the sane construction,you can
submit one,/orin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths ijdt#erent(example-3 rt 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
{1lrater lerel is above casing,use•-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (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
12.Well construction method: 6 5/8 HSA & 2 spoons 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. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Watei Resources Revised August 2013