GW1-2022-03327_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used f'or single or multiple wells l
I.Well Contractor Information:
Anthony Convery 14.WATER ZONES'
FROM TO DESCRIPTION
Well Contractor Name
4343
NC Well Contractor Certification Number 15.OUTER CASING formulti cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. j in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ". 10 ft. 14 in. SCh40 PVC
List all applicable melt pern ilc(i.e.Coungt Slate,Variance,Injection,ea•.)
ft. rt in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 30 ft. 2 rn' 1 .010 SCh40 PVC
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) ft. ft. in.
� ppY) pl Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 5 ft- Portland Cent Tremie
Non-Water Supply Well:
0 Mon itori ng ❑Recover_'
5 r' 8 rr Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI,ACEMENTMETIIOD
8 ft- 30 rr #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional lsheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION solar,hardness,saiurack type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-27-22 Well ID#AF-2
rt. rr.
5a.Well Location: ft. ft.
Colonial Pipeline Company rt. ft.
Facility/Owner Name Facility[DO(ifapplicable) -
ft. 13.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. MAR 1 4 2o29
Physical Address,City,and Zip
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN) ",--^--•. ,.��,th;;I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
f ifwell field,one lat/long is sufficient)
35.414877 Nr -80.806111
Sig nature ofCeni'ed Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hy signing this,lnrnn, rehy ceriili,r tat I ne well(,)uus(were)constructed in acc•ordonce
With 15A NCAC 02C.0100 or 15A NCA'02C.0200 Well Construction Slumlords and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the me//owner.
lflhis is a repair,.lill out known Well construction inlnrnmlian and explain rite nature ol'the
repair under-':1I remarks section or on the hack al7his,fornn. 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.
l•br nuhiple injection or non_
maler suppl y Wells ONLY With the same construction,you can
subma one lorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
boo nirdliple u•e/Is list all depths if c/tljerenl(example-3 a 200'and 2@/00') construction to the following:
i
10.Static water level below top of casing: Unknown (ft.) Division of Water Resources,Information Processing Unit,
I/)water/erel is above caring,use' :' 1617 Mail Service Cent4er,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In iaddition 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent`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
136.Disinfection type: Amount: well construction to the county health)department of the county where
constructed.
Form GW-I North Carolina Department of 6nviromuent and Natural Resources-Division of Water Resources Revised August 2013