WM0301152_GW_1 records for AS type wells_20220801

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For htteinal Use ONLY:
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit 11:
List all npplicuhle well permits (i.c•, t'auntr, Stale. Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (ileating/Cooling Supply) ❑.Residential Water Supply (single)
❑lndustrial/Commercial ❑Residential Water Supply (shared)
❑irrigation
Non -Water Supply Well:
[?(Monitoring ❑Recovers'
Injection V cIl:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling. Return) ❑other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-9-20 Well ID# AS-02
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification Na (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iadlong is sufficient)
35.412792 N-80.806405
6. is (are) the well(s): Cr7Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or R1No
1l this is n repair, Jill out known well construction in/brmation and explain the nature of the
repair under -?1 remarks section or on the hack 0/ this /arm.
8. Number of wells constructed: 1
14. WATER ZONES
FROM
TO
DESCRIPTION
27 ft.
29 rt.
wet
ft.
ft.
15. OUTER CASING (for multi -eased weJtk) 0R ANER (If appttc*ble)
FROM
TO
D1AMF.TER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TURING
(geothermal eloseddrloop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0 ft.
27 rt•
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
4$t)T SIZE
THICKNESS
\IATER.LAI.
27 ft.
29 ft.
2 in.
.010
sch40
pvc
tt.
ft.
in.
Ili. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
23 ft•
Portland Cem
Tremie
23 ft.
25 ft-
Bentonite Chi'
Tremie
ft.
ft.
19, S.4ND/Gtt. ,EL PACK
(if applic blel
FROM
TO
NI IIFRLtL
EMPLACEMENT METHOD
25 ft-
29 ft.
#1 Sand
Tremie
ft.
ft.
20. ARILUNG
LOG (attach
additional sheeta Winces' )
FROM
TO
DESCRIPTION (color. hardness. soil/ruck type, gain size, etc-)
ft.
ft.
ft.
ft.
tt.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature ofCertifted Well Contractor
-?��
Date
I)v signing this form, i hereby certify that the we/l(s) was (were) constructed in °craniance
with / i N('rl(' 02C .0100 or 15,1 NCA(' 02(' .0200 Well Conslruclon Standards and that a
copy u/ this record has keen provided to the welt owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
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 /item. SUBMITTAL INSTUCTIONS
9. Total well depth below land surface: 29 (FL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if li//weal (example- 3 n• ono' and 20100') construction to the following:
10. Static water level below top of casing: 27 (ft.) Division of Water Resources, information Processing Unit,
1/ water level is above casing, use " " 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 2 (in.) 24b. For Iniection 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 aueer, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Funv GW-I
North Carolina Department of -Environment. and Natural Resources— Division of Wateu Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
I. Well Contractor Information:
Kevin White
Well Contractor tame
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
!.ice nli applicably well permits If e 'OWNS, Ant', i "oriarrer, it/rciion. ete.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring LiRecovep
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatine/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Storm\vater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2 1 Remarks)
4. Date Well(s) Completed: 12-9-20
5a. Well Location:
Colonial Pipeline Company
Well 1D# AS-03
Facility/Owner Name Facility iDft (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PiN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laUlong is sufficient)
35.412731 N-80.806410
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ElNo
If this is a repair, till one known well can,lruclinn information and explain the nature of the
repair mu/er , 21 remarks .section or an the hack of this Mrs.
8. Number of wells constructed: 1
!ar multiple injection or non-waler.rnpplr wells ONLY with the same construction, von con
rhrhmil one /aria
9. Total well depth below land surface: 28 (ft.)
For multiple wells list a/1 depths if digerent (example- 3@200' and 20100')
ID. Static water level below top of casing: 26 (ft,)
If water level is above casing, use " ..
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i e auger, rotary. cable, direct push, eta)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
26 ft.
28 ft.
wet
ft.
ft.
IS. OUTER CASING (tor multi -used wells) OK LINER (If ap ticable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OK TE_!WING (geothermal elaeed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
26 tt•
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE.
THICKNESS
MATERIAL
26 ft'
28 tt.
2 in.
.010
sch40
pvc
ft.
ft.
in.
IS. GRfItrr
FROM
TO
MATERIAL
EMPL.WE\MEtit METHOD & %MO( NT
0 ft'
22 ft•
Portland Cem
Tremie
22 tt.
24 tt•
Bentonite Chi(
Tremie
ft.
ft.
�YDIGk4VEL PACK (if npplicabie)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
24 tt•
28 ft,
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION teedur, hardness, soil/ruck type. grain aize. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor
Date
By signing this forme, 1 hereby certify that the we//(s) was (were) constructed in accordance
with 15.-I N(".4(` 02(' (1100 or 15.4 N('A(' 02(' 0200 Well Construction ,SIo,dards and That a
cope' of this record has been prorided ur the we// owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this Form within 30 days of completion of' well
construction to the Following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Inieetii i :'cells:
Also submit one 'copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I Notch Carolina Department of Environment and Natural Resources-. Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For internal Use ONLY:
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC 1Ve':I Connactur Ccrritication Number
Parratt-Wolff, Inc.
Campam Name
2. Well Construction Permit#:
List all applicable well permits (i.e ('aunty, S'mte, I irri(IIrce, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
t@r Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
El Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-9-20 Well ID# AS-04
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IN (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Int/long is sufficient)
35.412578 „-80.806386
6. is (are) the well(s): LPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑%'es or )No
1/ 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 of this /orm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction. you can
submit one flow,.
9. Total well depth below land surface: 22
For multiple wells list all depths if different (example- 3, ?(10' and 2@100')
10. Static water level below top of casing: 20 (ft)
If water level is above casing, use "• "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i e. auger, totarv, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DFSCRti'TlON - - -
20 ft.
22 ft.
wet
ft.
ft.
1.4. DUTER CASING 1 armulti-cased wells) OR LINER (Rap !Roble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERTAL
0 ft•
20 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17, St.RF.EN
FROM
TO
DIAMETER
SLOT SIZE.
TRW K*I_SS
MATERIAL
20 ft.
22 it.
2 in,
.010
sch40
pvc
ft.
ft.
in.
iS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
16 ft.
Portland Cem
Tremie
16 ft•
18 ft
Bentonite Chil
Tremie
ft.
ft.
±<AND/CEIAVLt„ PACK(Ifappticnli)e)
FROM
TO
MATERIAL
E\IPL,iCE\IENf AIET'HOD
18 ft.
22 ft.
#1 Sand
Tremie
ft.
ft.
20. DRtl.l.I
tit; t.O I launch
addttiansli sheets If neerssaty)
FROM
TO
DESCRIPTION kola,. hardneol, suntruth type, train il'te, de.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REM. KS
No cover
22. Certification:
Signature of Certified Well 'rhnffitotni Date
By signing this /arnl, 1 /rerehp certify that the wen(s) was (were) constructed in accordance
trilh 15A NCA(' 02( 0100 or I5A N('AC 02C 0200 Well Construction Standards and that a
copy q/Yhis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTiONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
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
Reviser( August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2, Well Construction Permit #:
List all applicable well permits (i e. County, Stare, Variance, Injection, etc .1
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ElMonitoring ❑Recovery
Injection Weil:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwatcr Drainage
El Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-9-20 Well ID# AS-05
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one Iat/long is sufficient)
35.412535 -80.806399
6. Is (are) the well(s): GDPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ZNo
1/ this is a repair, fill out known well construction i fhrnlatinn and explain the nature of the
repair under '21 remarks section or on the hark of/his farm.
8. Number of wells constructed: 1
For multiple h jeclinn or non -water supply wells ONLY with the same construction, von can
submit one farm
9. Total well depth below land surface: 27.5 (rt.)
hbr multiple wells list all depths i/ different (example- 3@200' and 2 q l00')
10. Static water level below top ()leasing: unknown (ft.)
If water level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (far moIIi-e aed wefts) OR LINER (if np • Ile)
FROM
TO
DIAMETER
THICKNESS MATERI.II.
ft.
ft.
in.
16. INNER CASING OR TUBING (Centlurvu] eluuddoop)
FRDM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
25.5 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNFSS
MATERIAL
25.5 fit.
27.5 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
MATERIAL
EMPLACEMENT NIETROD & AMOUNT
0 ft.
20.5 fit'
Portland Cern
Tremie
20.5 ft.
23.5 it
Bentonite Chij
Tremie
ft.
ft.
19, SANWGRAVEL PACK
(lfaptdteabte)
FROM
TO
MATERIAL
EMPLACEMENT MtF.THOD
23.5 ft.
27.5 ft.
#1 Sand
Tremie
ft.
ft.
20. MUM
M 1;OG (attach addition si meets if necessary)
FROM
TO
DESCRIPTION Color.haniorss, xatrroeh type, grain sits. Cart
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
fit.
ft.
ft.
21, REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor
Date
By .signing this farm, I hereby certili that the well(s) wax (were) constructed in accordance
with 15A NCA(' 02(' 0100 or /5A N('AC 02(' 020(1 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection \%gilts:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan) Name
2. Well Construction Permit #:
List all applicable ire,/ permits (/.e (-wilily, Slate. r irriauce. lnlecliorr. etc.)
3. Well Ilse (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
❑Experimental Technology,
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-8-20 Well ID# AS-06
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
14511 Huntersville-Concord Road, Huntersville, NC 28078
Facility iDt/ (if applicable)
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PEN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
35.412317 N-80.806364
w
6. Is (are) the well(s): 17IPermanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or Elio
If this is a repair, Jill out known well construction information and explain -the nature ni the
repair under ,.21 remarks section or on the back nJ this throe
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sante construction, you can
submit one /iar»t.
9. Total well depth below land surface: 33 (ft.)
For multiple wells list all depths if d,tJkrem (example- 3@200' a» d 2 a l0(1')
10. Static water level below top of casing: 35 (ft.)
If water level is above casing use " - '•
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i,e: auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION.
33 ft.
35 ft.
wet
ft.
ft.
1S. OUTER CASING (for
multi eased aieils)OR LiNER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING
tacos ermat dnted.lagp)
FROM
TO
DIAMETER
THICKNESs
MATERIAL
0 ft.
33 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAME't ER
SLOT SIZE
THICKNESS
M.A1 ERIAL
33 ft.
35 fr.
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 fr•
29 ft,
Portland Cem
Tremie
29 ft.
31 ft.
Bentonite Chii
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLICEMEti fi mutton
31 ft.
35 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION Icahn.. hardness. soil/rock type, grain size, etc.(
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor
12 ZL
Date
By signing this P.m, I hereby certi/i' that the rrell(s) was (were) constructed in accordance
with 15A NC.4(• 02e ,0/00 or 1.iA MAC 02C .0200 Well Construction Standards and that a
copy (phis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTiONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection %%ell§ ONLY: in addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supplv x Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed..
Form GW-f North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable weil penults (i.e. ('omnr..State, Variance, 1njeciion, rlcj
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retuml
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-7-20 Well !IN/ AS-07
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412277 -80.806163 W.
6. Ts (are) the well(s): 1221Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or ENo
(f this is a repair,,/ill out known well construction iq%rntatian and explain the nature q(the
repair under 2/ remarks section or on the hack of this fiwm,
S. Number of wells constructed: 1
Far multiple injection or non -water supply arils ONLY with the same construction. you can
submit one horns
9. Total well depth below land surface: 38 (ft.)
for multiple wells /is/ all depths if different (example- 30200 200 ` and 2@/00')
10. Static water level below top of casing: 36 (ft.)
If water level is abore casing, use "- "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i.e, auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
I30. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
36 ft.
38 ft.
wet
ft.
ft.
15. OUTER CASING (far mutd taseii srelli i) OR LINER Of epeyeable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TT18ING (exothermal dosed -loop)
FitDM
TO
DIAMETER
TM ICKSFSS
A ATERtAI.
0 ft,
36 ft.
2 in•
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
:MATERIAL.
36 ft.
38 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLACEMENT MET! OD&AMOUNT
0 ft•
32 ft..
Portland Cem
Tremie
32 ft'
34 ft
Bentonite Chii
Tremie
ft.
ft.
19. SAND/GRAVEL
PACK (if appIcahle)
FROM
TO
MATERIAL
EMPLACEMENT ME IIOO
34 ft'
38 ft.
#1 Sand
Tremie
ft.
ft.
20. MULLING
LOG (attseh *ddf miat sheet® ifnecessary)
FROM
TO
DESCRIPTION tcotor, hardnes, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor Date
Kv signing this farm, 1 hereby certify that the wells) was (were) constructed in accordance
with 15A N('.4(' 02('.0)00 or 15A N('AC 02C .0200 Well Construction Standards and that a
copy nl this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
SUBMITTAL iNSTUCTIONS
24a. Fur All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
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 21)13

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC' Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all ripplicahle well pernri[s (i e• County, State, I%uriunce. 1r1/ecti(1n, eic.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
Non -Water Supply Well:
OMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
El Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-8-20
Well ID# AS-08
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one ladlong is sufficient)
35.412517 -80.805756
For Internal Use ONLY
I#. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
IL OUTER CASING (for could
-cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. IN ER
C<AS1"tG.OR TL BING (pot mist
ctoned4aap)
FROM
TO
DIAMETER
TItICI NF_S$
MATERIAL.
0 ft.
39 ft.
2 in.
sch40
pvc •
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL.
39 ft•
41 ft•
2 in.
.010
sch40
pvc
ft.
ft.
in.
la, GROUT
FROM
TO
MATERIAL
F_MPLaCE31EWT METHOD & AMOL NT
0 ft.
34 ft•
Portland Cem
Tremie
34 ft•
37 ft•
Bentonite Chii
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (if ap dic*ldell
FROM
TO
MLATERIAL
EMPIAC:EMENT NIETHOD
37 ft,
41 ft•
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additional sheets if areautary)
FROM
TO
DESCRIPTION {color. hardners..xuiIlrink type, erain sun,, ete.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
6. Is (are) the well(s): 12JPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or 21No
if this is a repair, Jill out known well construction infornraian and explain the nature a/ the
repair under •_?/ remarks section or on the hack of this farm.
8. Number of wells constructed:
For multiple in/ecriau or Harr -Caner supply wells ONLY with the same construction, you can
submit one farm,
9. Total well depth below land surface: 41 (ft.)
F'or multiple wells list all depths if -different (example- 3@?00' and 2(rv100')
10. Static water level below top of casing: unknown (ft.)
11 water level is shore casing, use "
II. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i e auger, rotary, cable; direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
22. Certification:
3• a2_• z\
Signature of Certified Well Contractor Date
By signing this farm, I hereby certify that the well(s) was (were) constructed in accordance
with 15,4 NCAC 02C .0100 or 15A NC'AC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
construction details. You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For .all Wells: Submit this Form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the tollowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county, where
constructed.
Forst OW-1 North Carolina Department of Environment and Natural Resources - Division of Water Resources
Rewised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compare Name
2. Weil Construction Permit #:
List all applicable well perrrrits (i, e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring ❑Recover
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-6-20 Well ID# AS-09
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IDd (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No, (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412477 N-80.805891 W.
6. Is (are) the well(s): )Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
lJ trig is a repair, fill out known well construction information and explain the nature of the
repair under =21 remarks section or on the back of this /itrtn,
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 40
For multiple welts list all depths !f different (example- 3 nn200' and 2@ro0')
(ft.)
10. Static water level below top of casing: 38 (ft.)
ifu ater level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
38 ff.
40 ft•
wet
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER ft f ap 0 able)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER C iSING OR TUFTING (geothermal cfosed-iuup)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
38 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
NIATER1AL
38 ft'
40 ft"
2 tn•
.010
sch40
pvc
ft.
ft.
in.
la. GROUT
FROM
TO
MATERIAL
EMPLICE:MENTAlErI OD Se AMOUNT
0 ff.
34 ff.
Portland Cam
Tremie
34 ft"
36 ft.
Bentonite Chi
Tremie
ft.
ft.
19, S:ANi1<GRAVEL P.#CK (if applicable)
FROM
TO
?MATERIAL
EMPM.A('E'VtENT METHOD
36 ff.
40 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG outset) additional ahem if necessary)
FROM
TO
DESCRIPTION (cvfnr, hardnccs. said/rock type, gexin st e, eli.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Stout ereofCertified We 'imtrucutr
Date
By signing this /anal, I hereby certify that the well(s) xis (rere) constructed in accordance
with l3A NCA(' 02(• .0100 or LEA N('A(' 02C _0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & injection Welts:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form G W- I North Carolina Deportment o f En viron meat and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits lee. ('uunly, .Blare, i arinuce, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑ irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Weil:
©Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
DGeothermal (Closed Loop) ,
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 12-5-20
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Well ID# AS-10
Facility iDII (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No: (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412585 N-80.805748
6. is (are) the well(s): @Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or EINo
IJ7his is a repair, fill nut known well cnnslruclio,, information and explain the nature of the
repair under ::21 remarks section or on the hack tJ this flaw,
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
.submit one frank
9. Total well depth below land surface: 37 (ft.)
l'itr omit/Fie wells IA't ‘dl thrill, a IiIIrent'example- 30200' and 2@I00)
10. Static water level below top of easing: 35 (ft.)
If grater level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i.e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For :met nal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
35 ft.
37 ft.
wet
ft.
ft.
ES OUTER CASING (far multi -cm ed wells) OR LINER (if applicabie)
FROM
TO DIAMETER
THICKNESS MATERIAL
ft.
ft. I in.
lti. INNER
CASING OR TI if1NG (geothermal elmed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
35 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
35 ft.
37 rt.
2 I.
,010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
MATERIAL
EMrL%cs ME;N'I METHOD Ss AMOUNT
0 ft.
31 ft•
Portland Cem
Tremie
31 ft-
33 ft.
Bentonite Chil
Tremie
ft.
ft.
19. SAND/GRAVEL
PACK
(ifapilica6lt).
FROM
TO
MATERIAL
EMPLACEMENT METHOD
33 ft.
37 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach addlbnn l sheet* if neeesastry)
FROM
TO
DESCRIPTION (color. hanIness. soitireck type. eeiiln aize. etc.)
ft.
ft.
ft.
ft.
fL
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor
(3 •Z_`
Date
By signing this /vrm, 1 hereby cernj' that the weii(.$) was (were) d astructed in accordance
with 15A NCAC 02(' .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the id! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Well§: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control.Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
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

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
RECEIVED/NCDEC.)/h)Nfl
MAR 2 $ ._ Uc'
WQROS
MOnRFFI 1NAL Of FI
List all applicable well permits (i.e. County, Sate, Variance, htjec•tion, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 11-22-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-1 1
Facility ID/4 (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City, and Zip
Mecklenburg
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well fieldone lat/tong is sufficient)
35.412856 -80.805488
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
/Jthi.s is a repair,1i11 out known well construction inlormatiot and explain the nature of the
repair under i2/ remarks .section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or not -water supply wells ONLY with the saute construction, you can
submit one farm.
9. Total well depth below land surface: 41• (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 38 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
( 19) 44-- 29
l/70)62.7 7izO
For Internal Use ONLY:
10811
14. WATER ZONES
FROM
TO
DESCRIPTION
38 ft.
41 ft.
wet
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
'E 16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft
40 ft'
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
39 ft.
41 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
36 ft.
Portland Cem
Tremie
36 ft
38 ft
Bentonite Chii
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
38 ft.
41 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
'
ft.
et
p \ L-.? .7-, v
ft.
ft.
MAR 15 2021
ft.
ft
ft.
ft.
I;`.. ;...��s3 ICC:uu^!ft�j Unit
`'iil��..`•
"�
ft.
ft.
r°,-,,i.:;ri,
I-, e i �. •
21. REMARKS
No cover
22. C'ertification:
Sign tare of Certified Well Contractor
(Z. Ls-Zo
Date
By .signing this form, / hereby certify that the well(s) was (here) constructed in accordance
with 15A NCA(' 02C .0100 or /5A N(A(' 02(' .0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW- 1
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
(. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, tolectimt, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
ft.
TO
ft.
DESCRIPTION
ft.
ft.
IS. OUTER CASING (for multiR LINER {(f appucable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
ft.
ft.
in.
FROM
tR C,ASING OR TUBING {geotherivat stated
-loop)
TO
DIAMETER
fillet:NESS
MATERI,1t.
0
ft.
61
ft.
2
in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12-12-20
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2I Remarks)
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Well ID# AS-12
Facility (D# (if applicable)
.14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, oue lat/long is sufficient)
35.413038 -80.805552
6. Is (are) the well(s): I22IPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
I/7his is a repair, Jill out known well construction in/brmation and explain the nature of the
repair under .'21 remarks section or on the back al this farm.
8. Number of wells constructed: 1
For multiple injection or non -[rater supply wells ONLY with the same construction, von von
.submit one farm
9. Total well depth below land surface: 63
!•'or multiple wells list all depths tl different (example- 31@ �00' and ?@ l00')
(ft.)
10. Static water level below top of casing: unknown (ft.)
)(water level is above casing, use " "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 I"iSA
(i:.e, auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MA1 ERIAL
61 ft.
63 et.
2
in,
.010
sch40
pvc
ft.
ft.
in.
ti3 G
FROM
0
ft.
TO
56
ft.
MATERIAL.
Portland Cem
EMPLACEMENT METHOD & AMOUNT
Tremie
56
ft.
59
ft.
Bentonite Chi
Tremie
ft.
ft.
19. SAND(GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
59
ft.
63
ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG tettseh additional sheen if necessary)
FROM
ft.
TO
ft.
DESCR IPTIO;N realer, hardness, Sefit wax, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
E.
Signature of Certified Well Contractor Date
By signing this Jornt, I hereby certify that lte bell(s) was (were) constructed in accordance
with /5A MCA' (I (' .0100 or 11A NCIC 02C .0200 Well Construction Standar& and that a
cope gl'this record has been provided to the we!! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details: You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For ,All WA: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW- I
North Carolina Department of Environment a
rid Natural Resources— Division of'Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
Lisl all applicable well permits (i e, County, State, 1'ariance. injection. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Rearm)
4. Date Well(s) Completed: 12/17/20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-13
Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City, and Zip
Mecklenburg
County Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
35.412977 N-80.805078
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or lifINo
//this is a repair, Jill out known well construction in fitrmaian and explain the nature al the
repair under -2/ remarks .section or on the buck q/thix farm,
8. Number of wells constructed: 1
For multiple uI/L 'lion or non -water supply wells ONLY with the same construction, you can
submit one form,
9. Total well depth below land surface: 71
For multiple wells list all depths if different (example- 3 .,200' and 2@ 100')
10. Static water level below top of casing: (ft.)
If water lerel is above casing, use "
1 I. Borehole diameter: 2 (in,)
12. Well construction method: 8 1/4 HSA
(f.)
(i.e. auger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DF.SCRIPTIO:V
rt.
ft.
ft.
ft.
15._OUTTER CASING (
mttttl cased lreps) t?R uOMRjirspp icsbio)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
t6. INNER
CASING t}I1 TUWNG
lgeetiurmat elmml--loop)
FROM
TO
DIAMETER
TtIIC1 NES,t
MATERIAL
0 ft.
69 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. REEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
69 ft.
71 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
la. GROUT
FROM TO
MATERIAL
EMPL.t(.'£.MENT. METHOD & AMOUNT
0 ft. 60 ft-
Portland Cem
Tremie
60 ft. 64 ft.
Bentonite Chi
Tremie
ft. ft.
i9,. $ANII/GRAt'EL PACK(ifapplieable)
FROM
TO
MATERIAL
EMPLA.TMENTMETHOD
64 ft.
71 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING
.LOG (4tittch
*ddi■cy)
FROM
TO
DESCRIPTION !color. hardaeas. tWit ock typr. grain 5ire,ctc.1
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. RtREM M INS
No cover
22. Certification:
Sipe ure of Certified Well Contractor
13v .signing ibis Jitrnt. / hereby certify that the we'll's) was (were) constructed in accordance
with l5A N('A' 02C ,O)00 or 15A NC'AC 02(' .0201) Well Construction Standards and that a
copy al this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details, You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For AM Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniection W'eItx ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
Form GW- I
Noith Carolina Department of Envitonntent and Natural Resources - Division of Water Resources Revised .August_013

WELL CONSTRUCTION RECORD
This form can be uscd for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compel)) Name
2. Well Construction Permit #:
Lisp all applicable well permits de : ratn,(r, Slate, I ariance, hl/celian, ere:)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
glMonitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Hefting/Cooling Return)
4. Date Well(s) Completed: 12/1 8/20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well I
AS-14
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(If Well field one IaU(ong is sufficient)
35.413007 N-80.804950
6. is (are) the well(s): 121Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Fes or ONo
If this is a repair, Jill out known well construction it jbrntation and explain the nature of the
repair under ,21 remarks section or an the hack a/ this limn,
S. Number of wells constructed: 1
For multiple in/ecton or non -water supply wells ONLY with the same construction, you can
submit one Jornr.
9. Total well depth below land surface: 61.5 (ft.)
For nmltiple wells list all depths if different (example- 3 tt 200' and 2@100')
10. Static water level below top of casing: (ft.)
If water /ere/ is shore casing, use "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA
(i,e.. auger, rotary, cable, direct push, etc..)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
For internal Use ONLY'
14. 'ATEER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. otrrF R CAS 1 ' f,, (for muff; -eased Wei OR LINEii of it co
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16.11YNER
CASING OR TURINGG (Rcotberatal etascd-ltwpl'
FROM
TO
DL\ME E.R
THICKNESS
MATERIAL
0 ft•
59,5 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
59.5 ft.
61.5 ft•
2 'n•
.010
sch40
pvc
ft.
ft.
in.
1d. GROUT
FROM
TO
11ATEItLAL
E:MPLtC.'EME\T METHOD & AMOUNT
0 ft.
54 ft-
Portland Cem
Tremie
54 ft•
57 11.
Bentonite Chi!
Tremie
ft.
ft.
t9,Sit�ii)/GRAVELPAC
(1fsiW)kirtbtal
FROM
TO
MATERIAL
EMPLACEMENT METHOD
57 ft'
61.5 fe-
#1 Sand
Tremie
ft.
ft.
20. DRILLING
LOG (attach additionat sheets ifnteesry)
FROM
TO
DESCRIPTION(color, bxrdnsss, 4erNock type. train silt. ete1
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21, REM Ft
No cover
22. Certification:
Signature of Certified Well ContracTor
'�
Date
Hy signing this fornr, l hereby certify that the well(s) was (here) constructed in accordance
with ISA N('AC 02(' , 0100 or 15,1 N(A(' (12C _ 0200 Well Construction Standards and that a
copy a/lhis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTIONS
24a. For. All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. Fur Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Forum GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This fbrm can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Cenificatiou Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits al?, (`panty, Stale. Variance. Iulection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Ind ustrial/Commercial
Orrrigation
❑Municipal/Puhlic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
El Monitoring ❑ Recovers
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) completed: 12/20/20 Well io# AS-15
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City, and Zip
Mecklenburg
County Parcel identification No: (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field; one Iat/long is sufficient)
35.413028. -80.804823
W
6. is (are) the well(s): ©Permanent or ❑Temporary
7. is this a repair to an existing well: Oyes or EINo
If this is a repair, Jill out known well construction MA -motion and explain the nature of the
repair Bander -21 remarks .section or on the hack of this fOrni,
8. Number of wells constructed: 1
For multiple injection or non -wafer supply wells ONLY with the same cnns/ructian, you can
.submit one firm.
9. Total well depth below land surface: 41 (ft.)
For multiple wells list all depths ifdillerem (example- 3uc200' mut 21 100')
10. Static water level below top of casing:
(f hater level is above casing, use "- "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i..e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For internal Use ONLY:
14. 1ATER zt�ntr s
FROM
TO
DESCRIPTION
fr.
rt.
ft.
ft.
15. DUTF.R CASING (for
ntttfti cased weiks) OR LINER (if app1kp6de)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
rt.
rt.
in.
Ib. INNER
CASING OR TUBING
(Ecoiberatal d aeal.1oap)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
39 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SUF.
THICKNESS
MATERIAL
39 ft.
41 ft.
2 In.
.010
sch40
pvc
ft.
ft.
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLACE:ME+t'r M THOD & AMOt NT
0 ft.
33 rt•
Portland Cem
Tremie
33 ft.
36 ft.
Bentonite Chil
Tremie
ft.
ft.
I9. SANOIGR#YEL
PACK(it»makable)
FROM
TO
MATERIAL.
E;MPLACEME?TT METHOD
36 ft.
41 ft.
#1 Sand
Tremie
ft.
ft.
21t, fRILI trtG
Lt (attach additional stscets If octetsaryl
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, erain sire, etc_)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
21. REMARKS
No cover
22. Certification:
Signature of Certified Well Contractor
j•zi
Date
13t' signing this /irrm, 1 hereby cerrijy that the well(s) was (were) constructed in accordance
with 15,4 NCA(' 02(' 0100 or 15A NAC 02C.0200 Well Construction Standards and that a
cant of this record has been pro•ided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMiTT.AL INSTUCTIONS
24a. For ,all Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Welk ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion Of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I
North Carolina Department of Environment and Natural Resotuces - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I, Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compom. Name
2. Well Construction Permit #:
I.irl all applicable well permits ru.e ('aunt..S'Onle, f irrrance, !Tection. etc.1
3. Well Use (check well use):
For Internal Use ONLY.
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
1S. OUTER C151PIG (fur mutt
FROM
ft.
TO
ft.
DIAMETER
k) OR LINER (If applicable)
in.
THICKNESS rATERtAL
)ti. INNLR CASING OR TUBING Igcothertna) cttraeti )wapl
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
28
ft.
2
in.
sch40
pvc
fI
ft.
in,
17-SCREEN
Water Supply Well:
❑Agricultural
❑Geotherma) (HeatingiCooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
7Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recover'
Injection Well:
Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-17-21
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Well ID# AS-16
Facility IDt4 (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lot/long is sufficient)
35.412252 N-80.806403
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ©No
// this is a repair. Jill out known well construction in/ornmtio, and explain the nature of the
repair under ' 21 remarks .section or MI the hock n/ this farm.
8. Number of wells constructed: 1
1' or multiple injection or tan -water supply wells ONLY with the sane construction, you can
snhmit one him.
9. Total well depth below land surface: 30
For multiple wells list all depths it titlerent (example- 3 1)200' and 20r 100')
(ft.)
10. Static water level below top of casing: None (ft.)
/J water level is above casing, use "
1 I. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA and 2" spoons
(i e. auger, rotary, cable, direct push. etci
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
'THICKNESS
MATERIAL
28 ft.
30 rt.
2
in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERI1t.
EMPLACEMENT METHOD & AMOUNT
0
ft.
24
ft.
Portland Cem
Tremie
24
ft.
26
ft.
Bentonite Chi(
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (tf applkaWe)
FROM
TO
MATERIAL
• i EMPLACEMENT MF,T1tOD
26
ft.
30
ft.
#1 Sand
Tremie
R.
ft.
20. DtfILL1NC LOCI
h attditie n
FROM
ft.
TO
ft.
DESCRIPTION [rotor. kantn
satt/roek type. grain
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
12" Cover
2 X 2 pad
22. Certification:
*oat re of Certified Well Contractor
I Z\
Date
By signing this Jnrn,, l hereby certify that the fret/(s) was (were) constructed in accordance
with 15.4 ,V(',4(' 02(' 0100 or 15.4 PV('A(' 02(' 0200 Well Construction Standards and that a
copy n/ this record has been provided to the Ind! ouvter.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the firm to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
- 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
Fo,m GW-1
Nosh Ca,olinu Department of Environment and Natural Rcsomces — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, inc.
Compare Name
2. Well Construction Permit#:
list all applicable well permits (le County, Sane, {'arcane, Injection, etc
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
c Monitoring
ORecovery
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-18-21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
0 Groundwater Reined iation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
OOther (explain under #21 Remarks)
well ID# AS-17
Facility 1D# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35.412265 N-80.806462
6. is (are) the well(s): ElPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well constnn•tlon in/brmation and explain the nature of the
repair under . 2i remarks section or on the back o/ this fnrni,
8. Number of wells constructed: 1
bur multiple injection or non -water supply Ire//s ONLY with the same construction, you can
submit one fawn{:
9. Total well depth below land surface: 42 (ft.)
For multiple wells /ist all depths if ililferetrt (example- 3 ii 200' and 2@100')
10. Static water level below top of casing: 30 (ft.)
1/ water level is above casing, use " - '
1 1. Borehole diameter: 2 (in,)
12. Well construction method: 8 1/4 HSA and 2" spoons
(i.eauger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FnOM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (far
multi -rattled welts) Ok E:INER (itunlivable)
FROM
TO
DIAMETER
THICKNESS
11.t.TERLAL
ff.
ft.
in.
16. INNER
CASING OR TUBING (geothermal daed-lonp)
FROM
TO
DIAMETER
THICKNESS
M.tTERL%L
0 ft.
40 ft.
2 tin•
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 rt.
42 ft.
2 in.
,010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM.
T'O
MATERIAL
EMPLACEMENT METI OD 4 AMOI NT
0 ft.
36 rt.
Portland Cem
Tremie
36 ft.
38 ft•
Bentonite Chi(
Tremie
ft.
ft.
19. SAND/GRAYE(.
PACK
f tf applfeshle)'
FROM
TO
MATERIAL
EMPLACEMENT METHOD
38 ft.
42 ft.
#1 Sand
Tremie
ft.
ft.
20. Ok1LI11VG'LOG
(nuxeh addiifaaat sheets li netessssei)
FROM
'I
DESCRIPTION (calm.. hartlnis.. oWVrvek t)in, er"ain irn. etc.)
ft.
ft.
ft.
fL
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
12" Cover
2 X 2 pad
22. Certification:
Signets Well Contractor
-7. La
Date
By .signing this /firm, I hereby certify that the wellre) was (were) consinteted in accordance
with 15A NC'AC 02C ,0100 or 15,4 NC'AC 02(' <0200 Well Construction Standards and that a
copy al this record has heen provided to ,he 'veil owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL iNSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Welk ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
Form GW-I
North Carolina Department or Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Lixi all applicable well permits (i.e. ('many. State, Variance, hljectinn, etc. i
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
i7iMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 4121 Remarks)
4. Date Well(s) Completed: 6-22-21 Well ID# AS-1 8
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifweii field. one lat/(ong is sufficient)
35.4123284 N-80.806907 W
6. is (are) the well(s): 12(Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or C+1No
if this is a rapair, Jill ant known well construction inhumation and explain the nature al tIu
repair under =21 rentarks.section or on the hack a/11tts form.
8. Number of wells constructed: 1
For multiple in/eclion or not -water supply wells ONLY with the same construction, you can
.submit une firm:
9. Total well depth below land surface: 46 (ft,)
For multiple wells list all depths if diffcrenl (example- 30200' and 2,@i00')
10. Static water level below top of easing: 37 (ft.)
If crater level is above casing, use " "
11. Borehole diameter: 2
12. Well construction method: 8 1/4 HSA and 2" spoons
(i..e: auger, rotary, cable, direct push. etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
OESCRII'TIoN
37 It.
46 ft.
Wet
ft.
ft.
IS. OUTER CASING tfur
much# eased welttl OR F Itit ft (lf sp i : able)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16.1NNER €ASING onTI7iiING (aeatheranal
clacett-toup)
FROM
TO
DIAMETER
THICKNESS
MATERUt.
0 ft'
44 fr.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIt;MtETER
SLOT SIZE
THICKNESS
M(ATERiAL
44 iL
46 rt.
2 in.
.010
sch40
pvc
ft.
ft.
in.
t8, GROUT
FROM
TO
MAATERIAI.
ES1 Pl. tf FMFNT MET( Otf,sk AMOt', NT
0 ft'
40 iL
Portland Cem
Tremie
40 It.
42 it
Bentonite Chi(
Tremie
ft.
rt.
I9. S.INB/halt AN' fit PAcKJtf
applicable)
FROM
TO
MAT£tt)AL
€MPL\CoMENT METHOD
42 f°
46 ft.
#1 Sand
Tremie
ft.
ft.
2U AAiLLfNG,LOG(>tttaehaddtetafralsheetstfneeeaaaiy)
FROM
TO
DF2tCRiPTiON ieolar, hardness, sa11/raek type: grain sue. Ctc,)
fr.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
re.
21. REMARKS
12" Cover
2 X 2 pad
22. Certification:
Si aat�t'Ce
tl Well Contractor
Date
Hy signing this firm, 1 /rereht certify that the well(s) was (were) consrntcted in accordance
with 15A N('AC 02(' .0100 or 15A NCAC 02(' .0200 Well Construction Sutndards and that a
copy of this record has been provided to the well owner
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. Frir Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
welI construction to the county health department of the county where
constructed
Form GW-I
Notch Carolina Department of Environment and Natural Resotuces— Division of water Resources Revised August 2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable well permits (i.e. (bunt! State, Variance. Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Tndustrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
iZ Monitoring ❑Recover'
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
OAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-23-21 Well iD# AS-19
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412371 N-80.807127 W
6. is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or EINo
If this is a repair, Jill out known well construction ilrforrtralion and explain the nature a/ the
repair under 2l remarks xeclian or on the back of this form,
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same eonsrrucrtnn, you can
.submit one Jam
9. Total well depth below land surface: 49 (ft.)
For multiple wells list all depths if'di(lerent (example- 30200' and 2Qi00')
10. Static water level below top of casing: 30 (ft.)
1/ wader level is above casing, use "
I I. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA and 2° spoons
(i.e. auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
W. WATER ZONES
FROM
TO
DESCRIPTION
30 ft'
49 ft.
Wet
ft.
ft.
IS. OUTER CASI2sG (far muff -cased welts) OR LINER (i€tp
hfe)
FROM
TO
DIAMETER
THICKNESS
M4TERIAL.
ft.
ft.
in.
16• INNL"R CASING 01t TifR NG($catkennxl cinaed-loop)
FROM
TO
DIAMETER
THICKNESS
MATFRu5t..
0 ft.
47 rt•
2 in.
sch40
pvc
ft.
ft.
in,
17. SCREEN
FROM
TO
DIAMETER.
SLOTSIZE
THICKNESS
NIATFRLtf.
47 ft.
49 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
ElIPt.ACFMEN f 1i ETt0OD &.\MOUNT
0 ft.
43 ft.
Portland Cem
Tremie
43 ft.
45 ft•
Bentonite Chii
Tremie
fr. ft.
19. SAND/GRAVEL PACK (if appliesb10
FROM
TO
MATERIAL
EMPLACEMENT' SI1T#IOD
45 ft•
49 ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attseh
sdditieotttahleta if essay i)
FROM
TO
DESCRIPTION !color. hardness. aoiIIrock type, grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
__ _........._.........
ft.
ft.
ft.
ft.
21. REMARKS
12" Cover
2 X 2 pad
22. Certification: [�
Signature aCO11 tied l Contractor Date
Hv signing this 1 rm, l hereby certt/y that the ne//(.r) was (here) constructed in accordance
with 15.1 NCAC 02C' .0100 or i3A NCAC 02C .0200 Well Construction Standards and shut a
copy of this record /,as been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For AR Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For liajection Wells ONLY: in addition to sending the form to the address in
24a above, also subunit a copy of this form within 30 days of completion of well
consttuction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply Sc Ittjectiom Welts:
Also submit one copy of this form within 30 days of completion of
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

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
For internal Use ONLV-
14. WATER ZONES
FROM TO
DESCRIPTION
40
ft,
49
ft.
Wet
ft.
ft.
15.. OUTER CASING lfar multi -hosed wcital OR LINER (If applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i,e. County. State. Variance, injection, etc t
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑industrial/Commercial ❑Residential Water Supply (shared)
❑irrigation
Non -Water Supply Well:
❑Monitoring ❑Recovery
injection Welt:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑ Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-24-21 Well iD# AS-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412599 N-80.807156
6. is (are) the well(s): 2IPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or 1No
1/ this ix a repair, Jill out knotrn well construction information and explain the nature 9/ the
repair under .2/ remarks .section or on the back ()phis lima
S. Number of wells constructed: 1
Far multiple injection or non -water supply wells ONLY with the same construction, you can
submit (Me film SUBMITTAL iNSTUCTiONS
9. Total well depth below land surface: 49
1-ar multiple wells list all depths i/different (example- RiD200' and 2,c0u 100')
10. Static water level below top of casing: 40 (ft.)
II water level is above casing, use " "
1. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 ("I SA
(; totluratsl eTait td tasp)
FROM
TO
DIAML"rER
THICKNESS
MATERIAL
0
ft.
47
ft.
2
in.
sch40
pvc
ft.
ft.
in.
SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS :MATERIAL
47 rt. 49 F° 2 in. .010 sch40 pvc
ft.
ft.
in.
1& GROUT
FRC/M TO MATERIAL EMPLAcEMl.vt Mt IHO113; %.MOUNT
0 ft. 43 rt. Portland Cem Tremie
43 ft.
45 ft.
Bentonite Chi l Tremie
ft.
ft.
19, SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
45 ft.
49
ft.
#1 Sand
Tremie
ft.
ft.
20. DRhLLiNG LOG tattae6 xafdltirusal sht cis if eesaart
FROM TO
fL
ft.
ft.
ft.
DFscnwwnoN (color, It glum.
iVr"ch type, grant site - etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
12" FMC
2x2 Pad
22. Certification:
Sire of Certified Well Contractor
(i e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Date
Hy signing this /orm, 1 hereby certify: that the well(%) was (were) constructed in accordance
with 1 SA N('AC 02C .0100 or I5A NCA(' 021' .0200 Wel1('otcttuetian Standards and that a
copy of this record has been prorided nt the well oirner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this torm within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department ofEnvironment and Natural Resources —Division of Water Resources
Revised August2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit ft:
List all applicable well permits (Le. (Ounty. Slaw, f ariance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
Non -Water Supply Well:
171Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Welts) Completed: 6-30-21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
Other (explain under #2 1 Remarks)
Well ID# AS-21
Facility ID* (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City. and Zip
Mecklenburg
County
Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
35.412834 -80.807217
6. is (are) the well(s): OPermanent or ❑Temporary
7. (s this a repair to an existing well: ❑Yes or ONo
If is a repair, fill out known well construction information and explain the nature the
repair under ,2/ remarkr section or an the back of this farm,
8. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same canstrucdon, you can
submit one /brut.
9. Total well depth below land surface: 61 (ft.)
For multiple wells list all depdu if di/fkrent (example- 3 t1 200' and 2 a !00')
10. Static water level below top of casing: 40 (ft.)
if water level is above casing, use " "
i 1. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i a auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
40 ft.
61 ft.
Wet
ft.
R.
IE OUTER CASING ffor multi -es with) €1R LINER Of apptkebie):
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
U. iNNFR
CASING OR TURING
(gent rat
clncetl-Iunp)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
59 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE.
THICKNESS
MATERIAL
59 (t•
61 ft•
2 in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
52 ft
Portland Cem
Tremie
52 ft
57 ft
Bentonite Chii
Tremie
ft.
ft.
19. SANDIGRAVEL PACK:
Of applkalste).
FROM
TO
MATERIAL
EMPI_:ACEMFNTMETHOD
57 ft•
61 ft'
#1 Sand
Tremie
ft.
ft.
20. AR{LLiNG
LOG (attach ndditiunat'<heets tf t raeasaty)
FROM
TO
DESCRIPTION (color.hanincss; sal/ruck rymc', eraiit vine. C.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
12" FMC
2x2 Pad
22. Certification:
Signailtr2`nt'Certifed Welt Contractor
Date
By signing this form, l hereby cerufi that Me well(s) was (here) cote:articled in accordance
with iSA N('A(' 02(' 0100 or ISA NC'AC 02C'.0200 Well Construction Standards and than a
cow of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary
SUBMITTAL iNSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For (niectton Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resoueces- Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i:e. ('uunte, State. 1 "arianee. injection, etc
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring 0 Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
0 Groundwater Remediation
OSalinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7-1-2Well ID# AS-22
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Nance Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.413085 -80.807237
w
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
1( this is a repair, Jill out known well construction in/ornation and explain the nature oldie
repair under -21 remarks .section or wi the hack of Ibis prim
8. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one Jitrnt.
9. Total well depth below land surface: 70
For multiple wells /is/ all depths i%different (example- 30200' and 2 a l00')
10. Static water level below top of easing: 40 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 2 (in.)
(ft.)
12. Well construction method: 8 1/4 HSA
(i e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
40 ft.
70 ft.
Wet
ft.
ft.
15. OUTER CASING (far multi -eased we [tcg OR LISER (if app Icahle)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
if.
in.
16. INNER CASING OR TURING
(geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
68 ft
2 in.
sch40
pvc
ft.
ft.
in.
17• SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL.
68 ft.
70 It
2 in.
.010
sch40
pvc
ft.
ft.
in.
19. GROLT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
61 ft•
Portland Cem
Tremie
61 ft•
66 ft•
Bentonite Chil
Tremie
ft.
ft.
19. S.iI.ND!GRAVEL FACT(
(if applteablt)
FROM
TO
MATERIAL
EMPLACEMENT METH OD
66 ft
70 ft.
#1 Sand
Tremie
ft.
ft.
2(t. DRILLING
LOG (attach additional sheets if tweeessary)
FROM
TO
DESCRIPTION (color, hardncsr: sad/ racktipe, grin the, etc.)
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
12" FMC
2x2 Pad
22. Certification:
62—) ‘6:
Signature of Certified Well Contractor Date
By signing this form, l hereby certify that the well(s) was (here) constructed in accordance
with l5A NC AC 02(' 0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. Fltr -UI Weill: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department or the county where
constructed
Fotm GW-1
North Carolina Department of Environment an
d Natural Resources- Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Companp Name
2. Well Construction Permit #:
List all applicable well permits (i..e.. ('otanv..Stale, f'ariance, !Medlin?. etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring ❑Recover'
injection Well:
❑Aquiter Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-10-21 well io# AS-23
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PiN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
if well field, one lat/long is sufficient)
35.413298 N-80.807262
6. is (are) the well(s): glPermanent or OTemporary
7. Is this a repair to an existing well: OYes or ElNo
1/ this is a repair. Jill au known well construction information and explain the nature all/re
repair Wander -21 remarks section or on the hack of this_ fihrnt,
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 69
For multiple wells list all depths i/ iliJJereru (example- 3@200 `ant 2‘11)/00')
10. Static water level below top of casing: 32 (ft.)
If water level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(ft.
(i.e. auger, rotary, cable, direct push. etc
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
Method of test:
13b. Disinfection type:
Amount:
For interna! Use ONLY
14. WATER ZONES
FROM
TO
DESCR1VT1ON
32 ft.
69 ft.
Wet
ft.
ft.
1S. Ot1TElt C %SING ffor multi cased wefts) C R UN R (if ep. ieable)
FROM
TO
DIAMETER
TII(CKNlrSS
MATERIAL..
ft.
ft.
in.
16. MINER CASING OR TURING (teethe rmal closed loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
49 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
1I1tC1{vt S.S
MATERIAL
49 ft.
69 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
MATERIAL
E.MPLaCEMENT:11ET1 OD&A:MMOt'Sr
0 ft'
61 ft.
Portland Cern
Tremie
61 ft•
65 ft.
Bentonite Chi]
Tremie
ft.
ft.
19. SA C V PACK
1 applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
65 ft.
69 ft.
#1 Sand
Tremie
ft.
ft.
20 fiRI1:I:1NG
Li7G (attatb
xdditiaaat cheers if nceaaary)
FROM
TO
DESCRIPTION (ruler, hardness, snit/ruck type. grain Nixt, ete.l
ft.
ft.
ft.
ft.
O.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
31 REMARKS
12" FMC
2x2 Pad
22. Certification:
4 tea l_.... --
Signu ire of C erti veil Contractor
Date
By signing this /'war, l hereby certify that the well(s) was (were) constructed in accordance
with 15.1 N('.IC 02C .0100 or ISA NcA(' 02(' ,0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCT(ONS
24a. Fur All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Welk ONLY: in addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form OW -I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August''-013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
I.,.st all applicable well pernnts (i.e. County. State, Variance. Injection. etc-.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
0 Industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
2 Monitoring
0 Recover),
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 12-9-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
0 Tracer
❑other (explain under #2I Remarks)
Well ID# PV-02
Facility IN (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
35.412529 -80.806391
6. Is (are) the well(s): )2lPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or JNo
If'this is a repair, fill nut known well construction inlhrmarion and explain the nature of the
repair under ,21 remarks' .section or on the back of'this firm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the saute construction, you can
submit one form.
9. Total well depth below land surface: 22.5
For multiple wells list all depths ifdifferent (example- 3 a 200' and 2 o I00')
10. Static water level below top of casing: None
I/\rater level is above casing, use
1 I. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA
(i.e. auger, rotary, cable, direct push. etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap limbic)
FROM _
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
7.5 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
7.5 ft•
22.5 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
I8. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 rt.
3,5 ft•
Portland Cem
Tremie
3.5 ft•
5.5 ft.
Bentonite Chi'
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
5.5 ft•
22.5 ft•
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
rt.
ft.
" iC '"j -:.' �..-::.v/
ft.
ft.
__..
ft.
ft.
MAR 1 5 2021
ft.
ft.
�• •. n 1 '.111
ft.
ft.
I' i.vr., t�!(yni 7i �...;
p ti ,c-� 0/.-1.tr...1D
!-1
21. REMARKS w
No cover
22. Certification:
Signature of Certified Well Contractor
Date
By signing this form. I hereby cerri/i' that the we/l(s) was (were) constructed in accordance
with I5A N('A(' 02C .0100 or ISA N('A(' 02( .0200 Well Construction Standards and that a
copy of this record has been provided to the we// owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW- 1 North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013