GW1-2022-01756_Well Construction - GW1_20220215

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 50 ft. Wet
2973 RECEIVED C C� ft. ft.
NC Well Contractor Certification Number v 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
FROM TO D1.4METER THICKNESS MATERIAL
Parratt-Wolff, Inc. FEB 15 2022 ft. 1 ft• I j in.
Company Name ,��M,.�t 16.INNER CASING OR TUBING(geothermal closed-loop)
Ifr1�P V( FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f 0 ft. 15 ft• 4 in. sch40 pvC
List all applicable well permits(i.e.CounN,Slate,Variance,hyection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 It. 50 fr. 4 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. Pt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 11 ft. ft- Portland Cem Tremie--
— Non-Water Supply Well:
_M Monitoring ❑Recovery
11 ft. 13 ft- Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 fit- 50 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fit. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary) r
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilimck type,grAin size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
4.Date Well 12-22-21 RW-105 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
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 lat/long is sufficient)
N W t fig a
Si nature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/herebv certify,that the trell(s)was(were)constructed in accordance
with I5A NCAC 01C.0100 or/.iA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ojthis record has been provided to the well owner.
If'this is a repair,fill out known well consiruc•lion iglbratation and explain the nature ol'the
repair under=11 remarks section or on the back gjthis form. 23.Site diagram or additional we'11 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 supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 24a. For All Wells: Submit this form within 30 days of completion of well
I•itr multiple wet/s/isl a/1 depths if dijJereni(example-3 , 00'and 2 rt/00') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
//barer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY; In addition to sending the form to the address in
6 5/8 HSA & Zrr spoons construction
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 Resource's,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 of completion of
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
f