GW1-2022-03320_Well Construction - GW1_20220314

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: l
+
Ga Ellin WOfth 14.WATER ZONES
rY J FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I
3367 ft. R.
NC Well Contractor Certification Number 15.OUTER CASING(for TaLtl-cased wells OR LINER if a livable
FROM TO DIAMETER 'I'H ICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. i in.
Company Name 16.INNER CASING OR TUBING. eothertnal closed-loo v
FROM TO DIAMETER "THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 11 R. 4 in. sch40 PVC
1.1si all applicable well permute(i.e.('aunt,,State, Variance,Dejection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 ft' 36 ft. 2 i"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 ft- Portland Cem Tremie
Non-Water Supply Well:
@ Mon i[oring ❑Recovery
6 ft. g ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a IicaVle
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 Is. 36 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental"technology ❑Subsidence Control 20.DRILLING LOG'iitfach'addifionalf'sheetsifnecessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suil/rucktype,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 1-25-22 Well ID#AF-7
rt. rr.
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
-
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it\veil field,one lat/long is sufficient)
35.414446 N -80.806706 N,
Signature ofCe ified Well Conte •tor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hr.aixning this jitr l hereby c•ertiJi,that the ire//(s)our(uereJ constructed in uccordnnce
02 .(l/llll or/SA N('A('d2('.112(I!1 Well('unslruc(iuu Slundur<Ic and thin n
7.Is this a repair to an existing well: ❑Yes or ElNo cow ql lhis record/tax heen provided to!De ire/l turner.
!/'this is a repair,fill out knou-n well construction inlnrmeation and explain the nature o17he
repair under=21 renearks.eec•tion or on the hack(if 1hic fi,rm. 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.
Por multiple it jec•tion or non-water supply wells ONLY with the.came construction,You can
submit one lornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 24a. For All Wells: Submit this form within 30 days of completion of well
bor wtthip/e wells lisl al/depths ifilillerent(example-3@200'anrl2 a 100') construction to the following:
Unknown Division of Water Resources Information Processing Unit,
10.Static water level below top of casing: (fL) i g
(/water level is ahnre caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In'addition to sending the torm 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 Centr,',: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.
Fornt GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013