GW1-2021-02213_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 40 ft 70 ft' Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 68 ft. 2 in. sch40 PVC
List all applicable we11 pennit.s(i.e.County.Stare, Pariance,hrjection,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 68 rt. 70 ft. 2 in.' .010 sch40 PVC
Supply) ❑Residential Water Supply ft. ft. in.
❑Geothermal(Heating/Cooling
PPY PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑irrigation 0 ft. 61 ft. Portland Cem Tremie
Non-Rater Supply Well:
61 rt• 66 ft- Bentonite Chil Tremie
2]Monitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Iicible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
66 70 #1 Sand Tremie
❑Aquifer Test ❑S[Ormwater 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 sim,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
7-1-21 AS-22 ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. F1"'
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS 1
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[at/long is sufficient/
-80.807237
35.413085 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing chix fbrm, 1 hereby certtfv that the we/1(s)was(were)constructed in accordance
With 15A NCA'02C.0100 or 15A 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 well ou ner.
If this is a repair,fill oar known well construction information and explain the nature of the
repair under=21 remarkv section or on the back o/'this jbrm. 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.
I'br multiple injection or non-water supply wells ON1.Y with the same construction,)you can
submit one jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-or multiple wells list all depths if dtjferem(example-1 a 200'and 1@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
//'water level is above casing,use'• " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA 24a above, 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 Environntcul and Natural Resources-Division of Water Resources Revised August 201?