GW1-2022-03268_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used fur single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 71 rt. I Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. tn.
Company Name 16.INNER CASING OR TUBING eoihermal dosed-loo
FROM TO DIAMETER : THICKNESS MATERIAL
2.Well Construction Permit#: 0 e. 26 ft. 4 in. SCh40 pvC
list all applicahle trell perndcv(i.e.County.Slate,Variance,Injection,etc.)
ft. ft. !in.
I
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTS17E 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 26 ft' 71 ft" 4 in. ' .010 sch40 pvc
❑Geothermal(Heating/C6oling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT !
FROM TO MATERIAL EMPLACEMENT❑METHOD&AMOUNT
❑lrri ation 0 rr. 22 It- Portland'Cem Tremie
Non-Water Supply Well:
❑Monitoring Recovery
22 ft. 24 ft- Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK"if:a" licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
24 ft' 71 ft- #1 Sand Tremie
❑Aquifer Test ❑Stonnwater Drainage ft. 1r.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach,iddilidnal's`heets f necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/tuck type,grain size,etc.
DGeothermal(Heating/Cooling Return) ❑ether(explain under 421 Remarks) ft. ft.
pW-1 1 2 ft. ft.
4.Date Well R 2-2-22
s)Completed Well ID# ft. fr.
5a.Well location: R. ft.
Colonial Pipeline Company 1t. fr. -
Facility/Owner Name Facility IDN(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN)
51h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
35.413560 N -80.805463 N, a-D0 al
Stg alure ofCertitied Well Con Factor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this jbon,I herehv certify that the well(s)was(were)constructed in accurdunce
trilh l SA NC'AC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Slanlarcly and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the trel/owner.
//'this is a repair,till out known trel/construction tnjornialion and explain the nature of the
repair under 1,21 remarks.section or on the hack of Ihi.c Jnrm. 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.
Pbr nnlliple injection or non-waler supply welly ONLY tridt the sane construction,you can
cuhnit one/brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 71 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1,or nnlliple toe//.v li.vi ail depths tjdtfjerent(example-3 cc.200'cold 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
//'traler level is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA & 2" spoons 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,Iludl erground 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 ofcompletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department o1'Enviromnenl and Natural Resources-Division of Water Resources Revised August 2013