GW1-2021-02593_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 30 ft' 60 ft' I Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ficable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. 1 in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 15 ft- 4 in. seh40 PVC
List all applicable hell permits(t.e.CounlY.Slate,Variance,h jecriar,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 It- 60 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 rt. 11 ft• Portland Cem Tremie
Non-Water Supply Well: _ _
- 11 ft. 13 rr• Bentonite`CChi Tremmie
Monitca-ng ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a ticible
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 ft- 160 ft- 1 #1 Sand I Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacheadditioniilsbeets if necessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 9-28-21 Well ID# MW-96
ft. fr. Nny 3 {
5a.Well Location: ft. ft. e7
Colonial Pipeline Company ft. ft. Ujt,,Rk;;l1UN1
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. rt.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 6"Stick up Cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: j
(ifwell field.one[at/long is sufficient)
35.415589 N -80.806413 W �k l �
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this Jinn,I hereby certifi,that the trellis)tras(were)constructed in accordance
with 15A 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 ZlNo copy oJ'dtis record has been provided to the well owner.
#this is a repair,fill out known wel/construction hijbrmation and explain the nature ollhe
repair tinder 21 remarks section or on the back g/7hts 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 supply wells ONLY with the same construction,you can -
submit one.1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 24a. For All Wells: Submit this form within 30 days of completion of well
Far ondorple wehs list all depdts iJ dijferent(example-3 a 200'and 2@/00') construction to the following:
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
If water lerel is above casing,use'•-" 1617 Mail Service C i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY:! In addition to sending the form to the address in
6 5/8 HSA & 2" spoons24aabove. also submit a copy of!,this form Within 30 days of completion of well
12.Well construction method: construction to the followimt:
(i.e.anger,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
V
i