GW1-2021-00243_Well Construction - GW1_20211213

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 35 ff 60 ff Wet
2973 a. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
FROM TO DIAMETER T THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It. 45 ft. 4 1n. sch40 PVC
List all applicable ire/l permits(i.e.Countr,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 45 It- 60 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 11 ft- Portland Cem Tremie
Non-IY'ater Supply Well: i --
11 ft- 13 ft- Bentonite Chi Tremie
�Monitoring ❑Recovers
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier- FROM TO MATERIAL EMPLACEMENT METHOD
13 ft. 60 f` #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock. e,.rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
9-23-21 MW-95 ft. ft.
4.Date Well(s)Completed: Well ID# fr. h. BEE 13 2021
5a.Well Location: ft. ft. °,°^, ._
Colonial Pipeline Company e. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 6"Stick up Cover
County Parcel identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient)
35.415538 N -80.806554 W. (c7 Z
Signature ofCerti red Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary Hv signing dus farm,I herekv certt/j that the well(s)was 6n ere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy o/this record has been provided to the well owner.
!/'this is a repair,Jill out known well construction information and explain the nature ofthe
repair under-,11 remarks section or an the back q/'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.
For multiple ittiection or non-water supply wells ONLY with the same construction,you can '
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For muhiple wells list all depths ifdt/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 (ft•) Division of Water Resources,Information Processing Unit,
//'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
6 5/8 HSA & 2" SpOOnS 24a above, also submit a copy of this form xxithin 30 days of completion of well
12.Well construction method: construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground 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 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