GW1-2021-07746_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD F i
I or Internal Use ONLY:
I This ibrm can be used forsingle or multiple wells
I.Well Contractor Information:
I Kevin White 14.WATBRZONES
FROM - TO DESCRIPf10�
Well Contractor dame ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number -,I&OUTER f YSING;formtttN-epMiv211s`OR'W1YE$ i"' bk
I FROM I TO DIAMETER THiCI aC1F5.4 1LATIIt1AL
Parratt-Wolff, Inc. fr.
Company Name :':ICDYNEB CASING'Olt TUBDVGGImeothernuill;eW ...FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 fr. 20 ft. 4 i" sch40 pvc
l,isf all applicable well penuits/i,e.Count.1%Mare.I ariance.Injection,etc.)
� ft. it. in.
3.Well Use(check well use): 1%SCREEN
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 20 R• 40 tc 4 '"' .010 Sch40 pvc
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) D n• m.
❑industrial/Commercial ❑Residential Water Supply(shared) 'ZIL-.GROUP
'FRDM TO ..MATERM& EMPLACEMENT MEmoD&AMOUti'r
Non-Water Supply Well: ..
❑Irri anon 0 ft• 15 ft Portland Cam Tremie
lZMonitoring ❑Recovery 15 ft. 17 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge []Groundwater Remediation 49 SAND/GRAVV0'AGB'.V
FROM - TO MATERIAL EMPLACEMENT METHOD.
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 ft• 39 tr. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
tr. fr.
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑ CRI
Tracer FROM TO OESPT1ON teall.r.'h-winw,aalltraek Imm vain Am.etc:
❑Geothermal WeaLlinglCoolinig Return) 00Lhcr.(,cxplain under#21 Remarks) fr. ft.
8-26-21 RW-80' fr. ft.
4.Date Well(s)Completed: Well[D#.
ft. ft IV
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. IL
tick
Facility/Owner Name Facility ID:(ifapplicable) - -
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft P;Qcasslng ll
fr ft InJOTM-31"',' 1 in
Physical Address,City,and Zip
Mecklenburg No cover
County Parcel Identification No.(PINT
5b.Latitude and Longitude in degrees/minutes/secands or decimal degrees: 22.Certification:
(if well Geld one lot/long is sufficient)
35.413810 N -80.806725 W.- r'1 9'QK- 6D c
:5ignatueofCettified Well Contractor Date
6.1s(are)the weil(s): OPermanent or ❑Temporary ty signing this jornr,1 hereby ceri!b,that the well(v)nas(were)catvirucled in accordance
with ISA N('AC 02C.0100 or 15A NCAC b2C,r1200 Well Consiructtar S'tahulaniv and thal a
7.Is this a repair to an existing well: ❑Yes or l?]No copy ofthis recard has been provided to the u•el/owner.
Y'llus is a repair,Jill oul known well cotntruen nh ioijn ruation and explain the nature of'ihe
repair under=2l remarks.section or air the back q1 d is,/itrni. 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: construction details. You may also attach additional pages if necessary.
For ondliple injection or non-water supply wells ONLY with the same ennstruction,wnt can i
submit one fi mh. SUBMITTAL INSTUCTIONS
9.Total well depthbelow land surface: 39 (f(:) 24a. For All-WcILS: Submit this form within 30 days of completion of well
TOW anhiple hells fist till tltptis ifdq@rent eexhaple-I(26200'and 2C100•) construction to the following:
10.Static water level below top of casing: (ft.) Division of water Resources,Information Processing Unit,
I/L•ater level is above casing,use•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 24b.For-Iniettion 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 8t 2 Spoons construction to the following:
(i,e.auger,rotary,cable,direct push,etc:)
Division of Water Resources,IT, derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a-Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this formlwithin 30 day,sof completion of
well construction to the coup health department of the county where
13b.Disinfection type: Amount: h� I p �'
constructed.
Form GW-I North Cwolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201?
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i
uparratt TEST BORING LOG 501 MILLSTONE DRIVE
wo1 1 lf1C HILLSBOROUGH,NC 27278
PROJECT Coloni" HOLE NO. mw- R7 D
LOCATION AvixWSvf lk, AJC. SURF.EL.
DATE STARTED IDjS);,Dz-i DATE COMPLETED lb`7I'ZAZ 1 JOB NO.o2oL{�0�0 L_
GROUND WATER DEPTH
N NO.OF BLOWS TO DRIVE SAMPLER 12"W/140#HAMMER FALLING WHILE DRILLING 50,
30" ASTM D-1586,STANDARD PENETRATION TEST BEFORE CASING
REMOVED
C NO.OF BLOWS TO DRIVE CASING 12"W/ #HAMMER FALLING AFTER CASINIG
"/OR /o CORE RECOVERY
0 REMOVED
CASING TYPE 6 V 14511,tPl Rho Zx,a ) , W P\)L , 37/9" Air e&koy SHEET OF I
SAMPLE STRATA
SAMPLE Jam DRIVE CHANGE
DEPTH DEPTH a� C RECORD N DESCRIPTION OF MATERIAL DEPTH
t+z PER6"
IS.6'
Zo
i
30,01 13L.0' s
0 Le
14o
qs# .o'
5bio,
0' 0' 10
019-Avqrr �
�' a.r hale co►lu�scd
SO
04 hole cb\1noc. 'AN
IUD J Ve'q! dnl
Sl�vtll �'ruc� 114'
Lit moislwt,
IN
133,
IHb �