GW1-2021-07743_Well Construction - GW1_20211116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: I '
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LIFER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I !in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rr. 15 ft. 4 in. Sch40 pvc
List all applicable hell permits(i.e.CounlY,Slate,I%ariance,Injection.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 f" 55 ft 4 "' 1 .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT i
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 1. 11 fl• Portland Cem Tremie
Non-Water Supply Well:
MMonitoring ❑Recovery 11 ft• 13 ft. Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
.. FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 ft• 55 ft• #1 Sand Tremie
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soillrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
4.Date Well 8-31-21 s)Completed: Well ID# RW-82
tt. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. NOV
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No cover Jc�'11v1v I 1 ivi?
County Parcel IdentificationNo.(PIN) tY ,;�; ., •ii
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) nn
35.414298 N -80.806506 W \ -P -( - 7• 2,(
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Rv signing This farm, I herebv cerii(D that due well(,)was(were)constructed in accordance
frith 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 copv ofihis record has been provided to the well owner.
if ihis is a repair,till out known well construction iglbrmation and explain the nature of the
repair under-21 remarks.section or on the back o/this Jorin. 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.
bor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depots#i4herent(example-3 co200'and 2 ci.l00') construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
ht water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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.aueer,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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form ywithin 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county healt h department of the county where
constructed.
Form GW-I Not Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013