GW1-2021-02208_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple swells
1.Well Contractor Information:
14.WATER ZONES
Kevin White FROM TO DESCRIPTION
Well Contractor Name
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells O LINER if a licable
FROM TO DIAMETERTOIL
TRHICKNESSI MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 40 ft. 2 in. SCh40 pvc
List all applicable well pernnis(i.e.Counhe State, Variance,h jec•lion,etc'.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'"'
❑Agricultural ❑Municipal/Public 40 ft. 42 ft. 2 .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(Single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 36 1` Portland Cem Tremie
Non-Water Supply Well:
36 ft 38 ft Bentonite Chil Tremie
@Monitoring ❑Recover
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. 42 ft.
#1.Sand Tremie
❑Aquifer Test ❑S[ormwa[er Drainage 38
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 Rewm) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 6-18-21 AS-17 ft. ft.
Completed: Well ID#
5a.Well Location: ft. ft. "_,i,
Colonial Pipeline Company ft. ft. 2
Facility/Owner Name Facility lD#(ifapplicable) R ft �jfl�t
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft ft. v
Physical Address,City,and Zip 21.REMARKS c V t
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 Iat/long is sufficient)
35.412265 N -80.806462 Wk,�,
( •Z l
Signalhire of Certified Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form, l hereby certify that the we/I(s)Bras(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑l'es or E]No copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction in(ornualion and explain the nature ojthe
repair under=21 remarks.section or on the back of lhi.s 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 multiple injection or non-water.suppli,wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 42 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list al/depths tfdt[ferent(example-3@200'and 2 a/00') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: fit addition to sending the form to the address in
spoons construction
above, also submit a copy of this form within 30 days of completion of well
8 1/4 HSA and 2
12.Well construction method: n 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