GW1-2021-02201_Well Construction - GW1_20210722

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
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased-wells OR LINER ifa ficable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. f[. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 10 ft• 2 in. SCh40 pVC
List all applicable well permits(i.e.Couniv,Stale,Variance.Injection,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 tt. 25 e. 2 rn' 1 .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 6 1" Portland Cem Tremie
Non-Water Supply Well:
6 ft- 8 fr. Bentonite Chil Tremie
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa Iicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 t`• 25 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach addifiotial sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
PV-12
4.Date Well 6-17-21 s)Completed: Well ID#
5a.Well Location:
Colonial Pipeline Company ft. ft. �� ►�,
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
14511 Huntersville-Concord Road, Huntersville, NC 28078 �`'1C►g U
ft. ft. „ Cr3�1001 �Q,=-4ron
Physical Address,City,and Zip 21.REMARKS V
Mecklenburg 12"Cover
County Parcel Identification No.(PIN) 2 X 2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient)
&-
35.412246 N -80.806439 W
S gna re of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this.form, I hereby certify that the rwell(s)was(were)constructed in accordance
with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Siondords and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy oJ7his record has been provided to the well owner.
1fihis is a repair,fill out known well construction information and explain the nature o(the
repair under,21 remarks section or on the back of ihisJorm. 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.
hor multiple injection or non-waier.supply wells ONLY rriih the same construction,volt can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 24a. For All Wells: Submit this form within 30 days of completion of well
For nntltiple wells list all depths ifififjerent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft l Division of Water Resources,Information Processing Unit,
1/'water level is above casing,rise" - 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 and 2" spoons24aabove, 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 C I enter,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 ofcomple[ionof
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