GW1-2022-01352_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple Hells
1.Well Contractor Information: r`
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 46 ft. �I Wet
2973 ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multl-eased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO I DIAMETER i I THICKNESS MATERIAL
2.Well Construction Permit#: 0 R. 11 ft. 4 '" sch40 PVC
List all applicable well permits(i.e.Counnv,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER! SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 ft 46 rt' 4 r°' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 7 fit. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 7 ft. 9 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.if a licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
fr•
❑Aquifer Test ❑Stormwater Drainage 9 46 ft. #1 Sand I Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionW sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
12-10-21 RW-100 ft. ft.
4.Date Wells)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. = p
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility IDk(ifapplicable)
ft. ft. jAN L
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. rt.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No Gover
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.414632 N -80.806403 W �L� 0 (- ID ZZ
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Rv.signing this Jorm,1 herebv certi&that the rvell(s)was/here)constructed in accordance
wtth 15A NCAC 02C.0100 or 15A NC*'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z1No copy oJ7his record has been provided to the well otrner.
ljthis is a repair,till out known well construction information and explain the nature oil the
repair under::21 remarks section or on the back oflhis Jorm. 23.Site diagram or additional well details:
You may use the back of this page'to provide additional well site details or well
8.Number of wells constructed- 1 construction details. You may also attach additional pages if necessan,.
For multiple injection or non-water sapply wells ONLY with the same construction,van can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•br nudtiple wells list all depths ifdiflerent(example-3@200'and 2@100') construction to the following: j
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY:!16 addition to sending the form to the address in
6 5/8 HSA & 2�t spoons24aabove, also submit a copy of1this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources)'Underground Injection Control Program,
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail Service CEenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 daysofcompletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013