GW1-2021-02175_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White e� TV;-
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name r-�/ ft. ft.
2973 I .G 1 2021 ft. ft.
NC Well Contractor Certification Number • 15.OUTER CASUVG for���+� DI A multi-case MET dFEwells OR LINER ifa cable)
FROM TO
Parratt-Wolff, Inc. _ at�o�processing ft. ft. R TT"
CKNESS MATERIAL
in.
Compam Name D��1 J- 16.INNER CASING OR TUBING geothermal closed-log
FROM TO DIAMETER THIC"FSS MATERIAL
2.Well Construction Permit#: 0 ft' 14.4 ft- 4 in. Sch40 pvc
List all applicable well permits(i.e.C'omnv,State,Variance.Injection,etc'.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER- SLOTSIZE THICINESS MATERIAL
❑Agricultural ❑Municipal/Public 14.4 f' 44.4 "' 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 EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft' 10.4 ft. Portland Cem Tremie
Non-Water Supply Well:
10.4 ft- 12.4 ft• Bentonite Chi Tremie
(7JMonitoring ❑Recovero
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEGPACK(if a Hcable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 12.4 1" 44 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soiVmck type,grain sin,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
rt. ft.
4.Date Well 5-27-21 RW-68s)Completed: Well ID# rt. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. R
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:
(ifwell field,one lat/long is sufficient)
35.415704 N -80.805670 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
/3v signing dtis form, /hereby cenifi-that the well(s)was(were)constructed in accordance
ieith 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 copy of this record has been pro rided to the we//owner.
tt'd is is a repair,Jill out known well construction iglbrmanon and explain the nature of the
repair under z21 remarkv section or on the hack of this farm. 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.
hur nuthiple injection or non-wafer supply wells ONLY with the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 44.4 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•'or multiple wells list all depths i/'t#ffereni(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,
lj'traler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY:'; In addition to sending the form to the address in
10 1/4 HSA& 2" SpOOr1S 24aabove, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: construction to the fallowing:
(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 within 30 days ofcompletion 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