GW1-2021-02594_Well Construction - GW1_20211130

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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 35 ft' 60 ft' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LTNER if a Gcable
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. 45 ft. 4 in. sch40 PVC
List all applicable well permii.s(i.e.County.State, Variance,hyection,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 45 ft. 60 ft. 2 in. .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f`. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 11 ft- Portland Cem Tremie
Non-Water-Supply Well: -_
rs 11 f` 13 ft Bentonite`Chi Tremie
OMonitorine ❑Recove
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 rt• 60 f` #1 Sand Tremie
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control _
20.DRILLING LOG attach additional sheets if necessa rb=
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soli/mck type,grain size,etc.Y g
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft.
4.Date Well 9-23-21 MW-95 ft. ft.
$)Completed: Well ID# ft. ft. r q
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft i NOV 0 M!
Facility/Owner Name Facility ID#(if applicable)
ft. f[.
14511 Huntersville-Concord Road, Huntersville, NC 28078 f[ a
Physical Address,City,and Zip 21.REMARKS t'
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:
(if well field one lat/long is sufficient)
35.415538 N -80.806554 W. ZA
Signature ot'Cem ted Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary Hv signing this fbrm,l herebv certily that the well(,)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
/60his is a repair,fill out known well construction information and explain the nature a/7he
repair under--21 remarks.section or on the back q/'ihis fbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
1 or multiple injection or non-water supply welly ONLY with the same construction,you can
submit one)ohm. 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 multiple wells list all depihs i(ih ferent(example-3 cCa200'and 2C/00') construction to the following:
10.Static water level below top of casing: 35 Division of Water Resources,Information Processing Unit,
(/'water level is above caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY:i In addition to sending the form to the address in
6 5/8 HSA& 2" SpOOnS 24a above, also submit a copy of ithis 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 f Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C 1 enter,Raleigh,NC 27699-1636
24c.For Water Supply&InjectionWells:
13a.Yield(gpm) Method of test:
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 esources Revised August 2013