GW1-2022-03258_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used I'm single or multiple wells
I.Well Contractor Information:
Anthony COnVery 14•WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4343 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. iu.
Company Name 16.INNER CASING OR TUBING etithermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft- in.
0 7.5 4 sch40 pvc
List all applicable weft pernlirs(i.e.Cotanv,,tilole, Variance,hlleclion,ele.) f[. fL in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.5 "' 17.5 ft- 2 in. .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD,k•AMOUNT
❑Irrigation 0 ft. 3 ft- Portland Cem Tremie
Non-Water Supply Well:
oMonitoring ❑Recovery 3 ft. 5 ft- Bentonite Chi Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLA TMENI'METHOD
5 rt• 17.5 rt• #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional rsheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soith.ck ty1m,grain slBe,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed- 1-31-22 Well ID#AC-3
ff. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID4(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 MAR ! 4
ft. 13.
Physical Address,City,and 7ip
21.REMARKS
Mecklenburg
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'svell field,one[at/long is sufficient)
35.414671 N -80.806146 W
Signature ofCertified W I Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Hp signing This/brit, lerehv c•ern&that I c s)eras(were)conx1rucled in accordance
with 15A NCAC 02C.0100 or 15A NCAC O'N'.02t10 If,//Construction Slundurds and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofilus record has been provided to the+ref/owner.
Il'lhi.s is a repair,Jill out known well construction inlorrealion and explain the nature of the
repair under::21 remarks section or cm the hack of this fora. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
bar multiple hyeclion or non-water.sapp4,welly ONLY with the same construction,You can
submit one.fornl. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 17.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/br nudtip/e ur/Ls/i.cl all depths it di//erent(example-3@200'and 2@/00') construction to the following: j
Unknown Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) g
//waler level is above casing,use"," 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In jaddition to sending the form to the address in
HSA w/ Geoprobe 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,Ilnlderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofconlplelionof*
13b.Disinfection type: Amount: well construction to the county healthl department of the county where
constructed.
Form GW-I North Carolina Department of E nvironnient and Natural Resources-Division of Water Resources Revised August 2013