GW1-2022-01358_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells 44
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 31 ft• 53 `t' Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi.cased wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: 0 ft. 28 ft. 4 t"• SCh40 PVC
List all applicable well permits(i.e.County,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 28 It- 53 rt' 4 in.' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. rr. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 24 ft. Portland Cem Tremie
Non-Water Supply Well:
�Monitorina ❑Recovery
24 ft 26 rt Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
26 153 `t1 #1;Sand I Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionil sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gmin sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
12-2-21 RW-97 f`' "
4.Date Well(s)Completed: Well IDii
ft. ft. i
5a.Well Location: ft. ft.
Colonial Pipeline Company a. e.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 J AN 2 4 U^�
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No Cover
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)
35.414892 N -80.805293 W
Signature of'Certifi d Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By,signing this form, I hereby certifv that the trellis)was(were)constructed in accordance
with 15A NCAC 02C.0100 or MA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofdn.s record has been provided to the well owner.
#'this is a repair/ill out known mell construction informalion and explain the nature ofthe
repair under c21 remarks.section or on the back q/'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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-[rater supply[cells ONI,Y with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 53 24a. For All Wells: Submit this form within 30 days of completion of well
Pnr multiple wells list all depths ifdilJereni(example-3C200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 31 Ift•) Division of Water Resoiurces,Information Processing Unit,
lfuater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: !In addition to sending the form to the address in
6 5/8 HSA & 2" SpOOnS 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.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Forst GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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