GW1-2022-03271_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:
Anthon Conve 14.WATER ZONES i
Y ry FROM TO DESCRIPTION
Well Contractor Namc ft. ft.
4343 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi--_`,wells OR.LiNER if a licable
FROM TO DLAMETER!, THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 6 fr. 4 in. SCh40 PVC
List all applicable irell permits(i.e.County,State, Variance,hyeelion,e14.)
fr. ft. in.
3.Well Use(check well use): 17.SCREEN p,
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6 f" 36 fr. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT }
FROM TO MATERIAL EMPLACEMENT ME"I HOD a AMOUNT
❑Irri ation 0 fr. 2 ft, Portland Cem Tremie
Non-Water Supply Well:
!7J Mon itori ng ❑Recovery 2 ft- 4 fr. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEM ENT M ETHOD
❑Aquifer lest ❑Stormwa[er Drainage 4 fir- 36 ft- #1 Sand Tremie
fr. fr.
❑Experimental Technology ❑Subsidence Control
20..DRILLING•LOG`attech`additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, win sirs,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft, i
4,Date Well(s)Completed: 2-3-22 Well ID4 -2
ft. ft.
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) MAR 1 -4 ft. ft. -
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft.
Physical Address,City,and Zip `
21.REDIARKS
Mecklenburg
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.414833 N -80.805337 Wa�-
-
SignatureofCertifiedWel ontractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv.signing 1hi.r Jornr, / tereh certify that the mell( tt (u ere)Colnslrucled in accordance
u•lih 15A NCAC 02C.0 or 154 W AC(12C.0200 Hlell('onslruclion Stundurds anti thal a
7.Is this a repair to an existing well: ❑Yes or ONo copy gJ7hi.s record ha.c been provided to the mell,,truer.
?I*Ihis is a repair,fill out knoirn well construction iglbrtnalion and explain the nature gl'the
repair under':21 remarks section or on the hack gf1hi.c/orm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-traler supply nrel/.s ONLY nriih the.came construction,you can
submit one jornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nu/liple tre/Lr/isv all depths tj'thIftrent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: Unknown (ft) Division of Water Resources,Information Processing Unit,
/j'ualer level is above eosin/;,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In!addition to sending the lot in to the address in
HSA w/ Geoprobe 24aabove, also submit a copy of this fnnn 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 Centi 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 days of completion of
13b.Disinfection type: Amount: well construction to the county healt I department of the counts'where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013