GW1-2021-02178_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2973 i VIN ft. ft.
tt' r�V1"k 15.OUTER CASING for multi-casc& ells OR LINER ifa licable
ParrattNC Well �Wolff'actor fInCcation dumber `�'3�tv� S$e 6T FROM ft TO ft DIAMETERrn THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING 2 eothe►mal closeddoo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 50 ft. 2 in. sch40 pvC
List all applicable trell permits(i.e.('aunty.State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 49 f`• 74 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 EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 32 ft. Portland Cem Tremie
Non-Water Supply Well:
32 ft 35 ft Bentonite Chi Tremie
2Monitoring ❑Recoven
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
35 ft 64 f' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 64 f`' 74 ft Sand(Riser)
20.DRILLING LOG attach addifroAal sheets ifnecesss"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin sin,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) R. ft.
R. R.
4.Date Well(s)Completed: 6/2/21 Well ID# MW-92
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 4"Pro Cover
County. Parcel Identification No.(PIN) 2 X2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 ertification:
7) 7­�
(ifwell field,one[at/long is sufficient)
35.414239 N -80.804402 W ().
Signature of Certifte well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this fbrm, 1 hereby certifi-that the trell(s)was(mere)constructed in accordance
With 15A NCAC 02C.0100 or 1 jA 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 provided to the mell owner.
Il7his is a repair,fill out known well construction information and explain the nature of the
repair under=21 remarks.section or on the back of 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 nudtiple injection or non-Crater supply is ONI Y it ah the same construction,you can
submit one fbrnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 74 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor nudtiple wells list all depths ifd##f rent(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 49 (ft.) Division of Water Resources,Information Processing Unit,
//baler level is above casing,use - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY:' In addition to sending the form to the address in
8 1/4 HSA & 2" Sp00nS 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:
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