GW1-2021-07747_Well Construction - GW1_20211116

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I WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor dame
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2973 ft. ft.
NC Well ContractorCertification Number A&OUTER.CASING,fornmltl-ca"weQi`INt:L1NER' f bk
FROM TO DIAMETER THiCI4�1);S.S 111TERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name : ti:EwMCASiNGOR.TQBiNG. _ dioued4iinall
FROM TO DIAMETER I THICKNms I MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft- 4 in. Seh40 PVC
[.;,fall applicable well pennies(i.e.Gaon.Sfate.I uriance.h jecihm,etc'.)
R. Ft. in.
3.Well Ilse(check well use): -i7 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 40 ff 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) ;tIL.GRO[Ff - -
FROM TO MATERIAL EMPLACE:MEXTM MOD&.AMOUNT
❑irri aeon 0 ft. 15 ft. Portland Cem Tremie
Non-Water Supply Well:
@Monitoring ❑Recovery 15 ft- 17 ft- Bentonite Chil Tremie
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19;S4NDi/ORA . _.ACC-'
.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPWCEMENTMETHOD
❑Aquifer Test ❑Starmwater Drainage 17 It. 39 ft. #1 Sand Tremie
ft. ff.
❑Experimental Technology ❑Subsidence Control _ _
❑Geothermal(Closed Loop) []Tracer -?FROO,M�T MAX DESCRIPTIGilON tar tuuaneu,,btvrodtw K libe.tic.�
❑Geothermal(Heatin Ctioliri Remm) ❑Other(explain under#21 Remarks) ft. ft.
8-26-2.1 RWwW ft. ft.ft. ft _�(,- !--! l lz-
4.Date Welts)Completed: Well[D#
NOV 16
5a.Well Location:
ft. ft. -1
Colonial Pipeline Company ft ft
I,tr
Facility/Owner Name Facility 1W(ifapplicable) ft. ft. t
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft ft
Physical Address,City,and Zip ..'II REKARXS..:„h .. ,.,,, ,�..x -u•a`a;r,
Mecklenburg No cover
County Parcel Identification No.(PiNI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lat/long is sufficient)
35.413810 N -80.806725 i,
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Sig(tqureofCenitied Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary Hy signing this frtrm,I hereby cenity' drat fire mell(s)iras(were)convirucled fit accordance
with 15A NCAC 0 C.0100 or ISA NUAC 0 C.0200 Well('aaan¢tion Siamlanls and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oftrus record has been provided to lire well corner.
/l'this is a mpair,fill out known @ell consintction information and erplam the nature gf1he
mpair under:21 remarks section or net the back q/'ll us,/irrnr. 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 malliple injection ar non-waier.supply u•eHs ONLY milh the same construction._vntt can
submit orte faun. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
piW anduple avl/.s)ist'R11.depths t/df)Jirenr/exanf&-32100'and 1C100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I/'uater level is obave casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 .(in.) 24b.For(niection Wells ONLY: In addition to sending the form to the address in
„ 24aabove, also submit a copy of,this form within 30 days of completion of well
12,Well construction method: 6 5/8 HSA&2Spoons 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
13a.Yield(gpm) Method of test- 24c.For Water Supply&Injectio WWells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county It I
department of the county where
constructed.
Form GW-I Nortlt Carolina Department of Environment and Natural Resowces-Division of Water Resources Revised August'_01?
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