GW1-2022-01353_Well Construction - GW1_20220124

p
i
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 31 ft' 46 ff Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased 71111s OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in,
Compam Name 16.INNER CASING OR TUBING(geothermal dosed-loci
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 21 ft. 4 i in. SCh40 pvC
List all applicable well permits(i.e.County,State,Variance,Injection,etc'.)
ft. ft. in.
3.Well Use(check well use): 1
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 21 ft' 46 ft' 4 in. .010 sch40 pvC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 17 1` Portland Cem Tremie
Non-Water Supply Well:
17 tt 19 ft Bentonite Chii Tremie
0 Mon itori na ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEG PAC K(if a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
19 ft' 46 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOGattach additionia sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 12-8-21 Well ID# RW-99
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. e.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. I
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. tr.
/a _G29
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN) ',J7v1 1
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient) 0
35.414161 N -80.805668 W ,� I 1- l - 1-2-2-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary ity signing dais jorm, I herehy certt&that the well(s)was(here)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z1No copy ofdus record has been provided to the we//owner.
Ifdds is a repair,fill out known well construction in/ormation and explain the nature ofthe
repair under=21 remarkv section or on the back of'this form. 23.Site diagram or additional well details:
You may use the back of this page;to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one jorrn. 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
For multiple wells list all depths tfch ereni(example-3 a 00'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft•) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use" 1617 Mail Service C i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA & 2tt spoons construction
above, also submit a copy of jthis form Nithin 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcomple[ionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i