GW1-2022-03259_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY: `
This form can be used for single or multiple wells
I.Well Contractor Information:
Anthon Conve 14.WATER ZONES
Y '7 FROM I'D DESCRIPTION
Well Contractor Name
4343
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,'wells OR LINER.if a livable
FROM TO DIAMETER I THICKNESS MA•fER1AL
Parratt-Wolff, Inc. ft. I ft. I i
Company Name 16.INNER CASING`OR.. BING eothermal closed-loo
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 fr. 19.5 ft. 4 '" SCh40 PVC
List all applicable meli permits(i.e.County,Siaie,Variance,hijection,etc,)
ft. I ft. I in.
3.Well Ilse(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.5 ff 29.5 fr 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑ anon 0 f3. 4 ft. Portland Cem Tremie
hJ Moni[ori ng ❑Recovery
4 ft 6 tr• Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.,SAND/GRAVELPACK ifi6 livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEfHOU
ft ft
❑Aquifer Test ❑Storm 6 29.5 #1 Sand Tremiewater Drainage rt. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG,attach"additional'sheets'if necessa-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION calm•,hardness,soil/ruck type, r-Ain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-28-22 Well ID#AC-2
ft. ft.
5a.Well Location: ft. ft. r '�' �- '(--}
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
MAR 1 14511 Huntersville-Concord Road, Huntersville, NC 28078 ` 20 '
ft. ft.
Physical Address.City,and Zip
21.REMARKS i -
Mecklenburg r
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)
35.414867 N -80.806097 W
Signature of Cendied Well ntractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv signing d;is Jbrn;, ;ere cerii/i ihat the a s)uws(mere)constructed in accordance
will;15A NCAC 02C.I 100 or 15A NCAC 02C.0200 Well('unslruciiun.lYundurds and Thai u
7.Is this a repair to an existing well: ❑Yes or EINo copy ojihis record l;a.s been provided to i/ie ltwe/l owner.
//'this is a repair,.lill out known well c•on.struciion inlorniation and explain the nature njihe
repair under c--21 remarks section or on the hack et/this lornt. 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.
Par nwhiple injection or non-water supply wells ONLY trait die same eonstritetion,pain can
submit one/brn;. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 29•5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Hirt•m;dtiple;veils list al/depths i/'difkrem(example-3 a,200'and 2 c,100') construction to the following:
10.Static water level below top of Unknown casing: (ft.) Division of Water Resources,Information Processing Unit,
l/(rater level is above casing,use" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: Inladdition to sending the form to the address in
HSA w/ Geoprobe 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
(i.e.auger,rotar),,cable,direct push,eta)
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centr,IRaleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24c.For Water Supply im 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 Environnient and Natural Resources-Division of Water Resources Revised August 2013