GW1-2022-01359_Well Construction - GW1_20220124

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 fr. 59 ft. y Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for
FROM TO mutAcMawRORLNR fa6cable
Ds ETE THES
MATERIAL
Parratt-Wolff, Inc. i in.
i
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fit. 19 ft. 4 in. sch40 PVC
List all applicable well permits(i.e.CounlY,Stare, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 19 ft. 59 f" 4 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 tt. 15 ft. Portland Cem Tremie
Non-Water Supply Well:
15 tr• 17 tr• Bentonite Chi Tremie
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
17 rr• 59 rr• #1,Sand Tremie
❑Aquifer Test ❑StormwaterDrainage tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG G attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. tr.
ft. fr. �
4.Date Well(s)Completed: 11-30-21 Well[D# RW-96
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility lD4(ifapplicable) ft. ft. JAN O
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
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 tat/long is sufficient)
35.414913 N -80.805352 W yll !\
Signature ofCCcrtified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing tus,/orm, I hereby certjy that the wells)was(were)consintcted in accordance
with 1 JA NCAC 02C.0100 or 15A NCA0 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy q1 this record has been provided to the well owner.
/f this is a repair,Jill our known well construction information and explain the nature of the
repair under-21 remarks 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-crater sapp/v wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 59 24a. For All Wells: Submit this'form within 30 days of completion of well
For nnihiple wells list at/depths if dr&rem(example-3 to 00'and 2 rr 100') construction to the following:
10.Static water level below top of casing: 31 (ft•) Division of Water Resources,Information Processing Unit,
/fwaterlevel is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: i In addition to sending the form to the address in
6 5/8 HSA & 2° SpOOnS 24a above, also submit a copy of,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 ResourcesJUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLI': 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. f
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013