GW1-2021-07740_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. It. F
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a Ncable
FROM TO L.1 1ETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 22 ft. 2 in. sch40 pve
List all applicable wellpermits(i.e.(oun{r,State,I'arianee,Injection,etc,.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural ❑Municipal/Public 22 ft' 37 ft- 2 in .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr. 16 IL Portland Cem Tremie
Non-Water Supply Well:
Zklonitorine ❑Recover 16 fr• 19 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft
❑Aquifer Test ❑Stormwater Drainage 19 fit' 37 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'LOG attach additional-sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)completed: 12-20-20 Well►D# PV-11
ft. ft.
5a.Well Location: ft. ft. NOV 1 6 ?021
Colonial Pipeline Company ft. ft-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. L1V7K Rtf PJPi
qpwrz
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft. v M '' '
Physical Address,City,and Zip 21.REMARKS,'-': t
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/lone is sufficient)
35.412952 N -80.804931 w ,�Pea� {N/`V\) \ • a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 211permanent or ❑Temporary By signing this 1brm, 1 hereby certijv that the we//(s)was(here)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 E]No copy of this record has been provided to the well owner.
4 this is a repair,full out known well construction information and explain the nature of the ii
repair under=21 remarks.section or oh the back o/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.
hor multiple injection or non-water supply ire/Ls ONLY with due same construction,you can
.subunit one/brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdtjjerent(example-3 a.200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
Ifirater level isabore casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA and 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.) 1
Division of Water Resources,,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
4
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 Environment and Natural Resources-Division of Water Resources Revised.August 2013
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