GW1-2022-03260_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Anthony4.WATERZONEs��
nthony Convery
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4343
NC Well Contractor Certification Number IS.,OUTER CASING foF multi-cased,wells?OR`LINER if a "livable'
FROM TO DIAMETER k ! THICKNESS MATERIAL
Parrott-Wolff, Inc. fl. ft. in.
Company Name tb:1NNER CASING'sOR", [TBING. eothertital closed-loo
FROM TO DIAMETER - THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 12 ft- 4 t"• sch40 pvc
List all applicahle well pernins(i.e.CounlY,Stale,Variance,Injection,etc.)
ft. ft.
3.Well rise(check well use): 17;SCREEN ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 1%,I.A'1'ERIAL
❑Agricultural ❑Municipal/Puhlic 12 R' 32 R• 2 i"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18:eGROUT ,r k. k
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 7 ft- Portland Cem Tremie
Non-Water Supply Well:
❑OMonitoring ❑Recovery 7 tr' 10 fr• Bentonite'Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation +,19.,SAND/GRAVES PACKi if,a"1icable
FROM TO MATERIAL i EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
10 fr• 32 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRII LING;LOG.atfacti additional s tiee'fa;if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION cola-,hardness,suit/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 1-26-22 s)Completed: Well ID#AB-6 ft. ft.
5a.Well location: ft. ft.
Colonial Pipeline Company fr. fr,
MAR 1 4 ?
Facility/Owner Name Facility ID#(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degree's/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ladlong is sufficient)
35.414270 -80.806340
W VL_
Signature of Certified W=ce
ctor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this/brin, l ltify that the we nvas ere)cuniirucled in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consu'ucnion S7andurds and thin a
7.Is this a repair to an existing well: ❑Yes or ONo copy ojthis record has heen provided to the well owner.
1 f this is a repair,fill out known well c•onsiruelion in/brnration and explain the nature of the
repair under 21 remarks section or on the hack q/Phis Jbrin. 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.
Far multiple injection or non-waver supply wells ONLY with the.sane construction,you call
submit one,lbrin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple we//.c list all depths i/'di//erenn(example-3 a 200'and 2@100') construction to the following:
Unknown Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) g
4 water level is above casing,use 1617 Mail Service Cent er,'Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b, For Injection Wells ONLY: In addition 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.e.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent'r,'!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 daysofcompletion of
136.Disinfection type: Amount: well construction to the county health'department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013