GW1-2021-07739_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple swells 1,
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
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. I in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-Imi
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.Coun(v,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 "' 30 ft- 2 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 EMPLACEMENTMETHOD&AMOUNT
❑)tri ation 0 f[. 4 ft• Portland Cem Tremie
Non-Water Supply Well:
f7JMonitorine ❑Recovero
4 ft 11 ft Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11 ft• 30 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifiotW sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION lcolor,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/CoOling Return) ❑Other(explain under#21 Remarks) ft. ft.
C �
4.Date Well 6-30-21 PV-18 ft. ft.
$)Completed: Well ID# ft. ft -
5a.Well Location: ft. ft. NO V 1
Colonial Pipeline Company ft. ft +
Facility/Owner Name Facility ID#(if applicable) f[ t rye. iGP7 t
. ft. j (JU:•�JCC�
14511 Huntersville-Concord Road, Huntersville, NC 28078 ^" '
ft. ft. -.r;r111t l" 'I�UCESSING U1411
Physical Address,City,and Zip -
21.REDfARKS
Mecklenburg
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)
35.413195 N -80.807544 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing This form,1 herebv ceMl.i,that the well(s)was(here)constructed in accordance
with I5A NCAC 02C.010t1 or 15A NCAC 02C.0200 Well Construction Standards and that o
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction infbrmation and explain the nature ofthe
repair under 21 remarks section or on the hack grthis fbrm. 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 necessar\.
l'or multiple injection or non-water supply wells ONLY with the same construction,you can
suhnin one jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-"or multiple wells list all depths i/dl#mnt(example-3C200'and 2 ri1100') construction to the following:
10.Static water level below top of casing: 25 (ft,) Division of Water Restiurces,Information Processing Unit,
/floater level is above casing,use--- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY:I In addition to sending the form to the address in
8 1/4HSA & 2" SpOOnS 24aabove, also submit a copy ofithis 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(enter,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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. a
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013