GW1-2022-03270_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used fur single or multiple wells
1.Well Contractor Information:
Anthony Convery 14;WATER,ZONES y
FROM TO JMCRIPTION;
Well Contractor Name
4343
f '
NC Well Contractor Certification Number 15.OUTER CASING fornitilti=cased wells OR LINER if a licable
FROM TO DIAMETERP THICKNESS MA"1'ERIAL
Parratt-Wolff, Inc. ft. ft. fin.
Company Name 16 INNERIC-ASING OR'TUBING' eothermal closed-loo
FROM I TO DIAMETER! I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 7 ft. 4 iin' sch40 PVC
Lis/all applicahle+cell permits(i.e.Coun/Y,blare,Variance,htjectian,etc.)
ft. ft.
3.Well Use(check well use): 17'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 ft' 32 ft. 2 " .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GROUT,
FROM TO MATERIAL. EMPLACEMENT METHOD AMOUNT
❑irri ation 0 ft. 3 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
3 ft. 5 ft- Bentonite Chii Tremie
Injection Well: rt. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK;if,"a""licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 5 rt. 32 rt. #1 S'and Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
s203DRILLINGiUOG'affaih',additional(s`heetsifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION calm,ha+dness,suil/hmck type,gmi.size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-31—22 Well ID#AA-3
ft. ft.
52.Well Location:
Colonial Pipeline Company e. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ff.
LAAM
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. fr.
Physical Address.City,and Zip
2lL REMARKS ('
Mecklenburg
County Parcel Identification No.(PIN) r �`�•_ . ..
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one lat/long is sufficient)
35.414436 N —80.806946 W �} Cp o� . i� a a-
SignatureofCerti tied W Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary BV signing this farm, /wrew cerg1j,that the ire//(s)rrav(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well('unstructiun blundurds and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/1hi.s record has been provided to the we//owner.
1/lhis is a repair/ill our known well construction in/orniation and explain the nature ofilre
repair under,.21 rentarks section or on the back o/'this/irrni. 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-irr multiple injection or non-water supply wells ONLY with the same construction,You can
submit onefhrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1,'or multiple wells li.ci al/depths#diijprent(example-3 a@11/0'and 1 tr/00') construction to the following:
10.Static water level below top of casing: Unknown (ft.) Division of Water Resources;Information Processing Unit,
tf water level isabove casing,use" 1617 Mail Service Center,';Raleigh,NC 27699-1617
i
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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent er,!,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Well`s:
Also submit one copy of this form wrthin 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013