GW1-2022-03263_Well Construction - GW1_20220314

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Anthony Convery 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name ft. rt.
4343
NC Well Contractor Certification Number 15.OUTER CASING(for mu'7 cased wells OR LINER'if.a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR".. BING`"'edthermal closed-loo
FROM TO DIAMETER : THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 11 ft. 14 in sch40 PVC
List all appheahle well permits(i.e.Counry,Stale,Variance,Injection,etc-.)
ft. ft. I in.
3.Well Ilse(check well use): 17.SCREEN 4
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 ft' 36 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT' 9
FROM TO MATERIAL EMPLACEMENTNIETHOD&AMOUNT
[Irrigation 0 ft. 6 It- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
6 rt. g fr. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK,`if a"'licahlc
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g rt. 36 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage tt. rt.
❑Experimental Technology ❑Subsidence Control
'30.DRILLING;LOG attech'fdditionallshiets`.if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sirx,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
rt. sr.
4.Date Well(s)Completed: 2-1-22 Well ID#AB-`;
5a.Well location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) -
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. rt. AAAD
i
Physical Address,City,and Zip 21.REMARKS r
Mecklenburg
County Parcel Identification No.(PIN) • '�' -"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one W/long is sufficient)
35.414540 N -80.806160 N, --Q . (�(•a a
Sig iature ot'Certitied Well Co actor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this form,I her lift,Not the well(,)uws constructed in accordance
with 15A NCAC 02C.0l110 or 15A NCAC 02C.0200 Well Construction Standurds and that a
7.Is this a repair to an existing well: 01'es or ZlNo copy ofihis record has been provided to Nte hell owner.
4 this is a repair,,litl out known well c'onstruclion inliermalion and explain the nature of the
re/xtir ender--21 remarks section or on the hack q/(Ntis./orm, 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.
l-or mulliple injection or non-eraier supply❑'ells ONLY milli the some construction,you can
suhmit one form. SUBMITTAL INSTUCTIONS
i
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•or mulliple wells list all depths i/c/i/Jerenl(example-3(200'and 2«l00') construction t0 the following:
Unknown Division of Water Resources'Information Processing Unit,
10.Static water level below top of casing: (ft.) i g
I/lraler level is ahore caving,use 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In!addition 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centlr,',Raleigh,NC 27699-1636
I3a.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
consuucted.
Forni GW-1 North Carolina Department of Environntent and Natural Resources—Division of Water Resources Revised August 2013