GW1-2021-02212_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Kevin White FROM
WATER ZONES DESCRIPTION
Well Contractor Name 40 f` 49 r`' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for mWti cased wells OR LINER if a fieable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. 11. ft. I . in.
Compam Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 47 ft. 2 in. sch40 PVC
List all applicable ivell permits(i.e.('aunty.State. Variance,Injection,etc.)
ft. (L in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'"'
❑Agricultural ❑Municipal/Public 47 ft. 49 ft. 2 010 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 EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 43 ft. Portland Cem Tremie
Non-Water Supply Well:
43 f` 45 f` Bentonite Chil Tremie
RlMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Recovery ❑Salini Salinity
45 f`• 49 f`• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifion'al sheets if necesss
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Jeolor.hardness,soil/rack type.grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 6-24-21 s)Completed: Well ID#AS-20 ft. ft.
rt. a.
5a.Well Location: ft. R.
Colonial Pipeline Company ft. ft. ¢
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 1
14511 Huntersville-Concord Road, Huntersville, NC 28078 c3
ft. ft.
Physical Address,City,and Zip 21.REMARKS n ',rJ`Jtt t`
Mecklenburg 12"FM(R oar., t'°r;;� ;;Qc��'
County Parcel Identification No.(PIN) 2X2 Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
35.412599 N -80.807156 W. ��, ( •
Signs re ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hi;signing this jbrm,I hereby cerigl-that the well(s) qas(here)constructed in accordance
m1h I5A 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 EJNo copy glthis record has been provided to the melt owner.
l)this is a repair,Jill out known m ell construction in)brnmtion and explain the nature of the
repair ender�21 remarks section or on the back r#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 necessan.
For multiple injection or non-crater supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 49 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nnehiple wells list all depths if differeni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft•) Division of Water Resources,Information Processing Unit,
ll uvier 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
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 m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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