GW1-2021-02174_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.��� '
2973 �
1 15.OUTER CASING for multi-cased wells OR LINER if a licable
NC Well Contractor Certification Number 2p1
FROM TO DIAMETER THICKNESS 1ATERIAL
Parratt-Wolff, Inc. ��1� Rca��tit rt. ft. in.
Compam,Name t (C 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: �\t10IC;,3I zifP, ��On FROM TO
ft' ft DIAMETER in. THICKNESS MATERIAL
15 4 sch40 PVC
List all applie•able well permits(i.e.C'ouunv,Store.I%urianc•e,byec•tinu,eK'.) 0
ft. ft. in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 fL 50 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 1. 11 ft- Portland Cem Tremie
Non-Water Supply Well:
OManitoring ❑Recoven
11 ft- 12 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 12 ft' 50 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft. ft.
5-26-21 RW-67 ft rt.
4.Date Well(s)Completed: Well ID# ft.. ft.
5a.Well Location: ft. rt.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) rt. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
21-REMARKS
Mecklenburg No cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one[at/long is sufficient)
34.415715 N -80.805485 W. (4
S gnalure of Certified Well Contra or Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this form, 1 herebv certifi,that the wells)it as(were)constructed in accordance
with I5A 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 ElNo copy glthis record has been provided to the well owner.
I/'this is a repair,full out known well construction iglornnotion and explain the nature ojthe
repair under 21 remarks section or on the back qJ this.1bruu. 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 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: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bbr multiple wells list all depths IJ different(example-3@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,
Ifwaterlevel 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
10 5/8 HSA& 2" SpOOrIS 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,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 within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Forni GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013