GW1-2021-02177_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 FROM
WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name � 32 ft• 69 ft' Wet
2973 1 ft. ft.
NC Well Contractor Certification Number .J U L Z02" 15.OUTER CASING for multi-eased'wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. sq ;)fccessing Unit ft. ft. in.
Company Name pvvrR Se'=O 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 49 ft. 2 in. SCh40 PVC
List all applicable+cell permits(i.e.Couniv Slate.Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 49 ft' 69 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[ irrigation tt. R.
0 61 Portland Cem Tremie
Non-Water Supply Well:
0 Monitori ng ❑Recovery
61 ft. 65 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a lidible
- FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 65 ft' 69 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,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 6-10-21 Well ID#AS-23
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg 12"FMC
County Parcel Identification No.(PIN) '2x2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one lat/long is sufficient) D / 4
35.413298 N -80.807262 W V19C0 .4LIZ-ZI
SiEna re ofCcritfIttrVell Contractor ! Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hy signing dhis./irrnt, !herehv c•ertijv that the we//(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ql this record has been provided to the well owner.
!%this is a repair/ill out known well construction information and explain the native of the
repair under<21 remarks.section or on the back gI'dus 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.
har multiple injection or ton-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 69 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths iJdifJereni(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 32 (ft•) Division of Water Resources,Information Processing Unit,
If wafer level is abore caring,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
8 1/4 HSA 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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&Injection Wells:
i
Also submit one copy of this form.within'30 daysofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013