GW1-2021-02591_Well Construction - GW1_20211130

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 ff 59.5 ff Wet
2973 D. e•
NC Well Contractor Certification Number 15.OUTER CASING for multi cased,wells OR LINER ff a Hcable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I , in.
Company Name 16.INNER CASING OR TUBING eothermal closed400
WR0300120 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 1 g 5 ft- 4 '"• SCh40 pVC
List all applicable well permits(i.e.Countyt 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 19.5 ft. 59.5 ft' 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
[ Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ti. 14 ft. Portland Cem Tremie
Non-Water Supply Well:
14 ft- 16.5 ft- Bentonite'Chi Tremie
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 16.5 fr' 59 5 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG;attach Additionil`sheeti,if necessa ;, s,<._�- &r- -F
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soivmck type,prain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 1 1-17-21 Well ID# RW-93
5a.Well Location:
Colonial Pipeline Company ft. ft. NOV 3,0 2
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. fr. ZZL ll ;l;
Physical Address,City,and Zip M n�lLa+.ar v i non .P.
21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one[at/long is sufficient)
35.412285 N -80.806265 W. X "_�
Signature of'Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Hv signing this form, I hereby certijv that the well(s)eras(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy o/this record has been provided to the well owner.
//this is a repair,fill out known well construction information and explain the nature of the
repair under-21 remarks.section or on the back q('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 nnoluple injection or non-haler.supp/v wells ONLY frith the same construction,you can
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 59.5 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For nudtiple irel/s list all depths i/'dt f/erenl(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
/Jtrater le re/is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Weill ONLY: 'In addition to sending the form to the address in
6 5/8 HSA , 4" PVC, & 2t� S OOrIS 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
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 forth within 30 days ofcomple[ionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1