GW1-2022-03664_Well Construction - GW1_20220321

E
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 42 f`• 55 f`• 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. f, ft. Iin.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft. 4 [in. seh40 PVC
List all applicable well perntit.v(i.e.Coun(v,Stale,Variunc•e,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER (SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 55 ft. 4 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT NETHOU do AMOUNT
❑lrri ation 0 rr. 11 ft- Portland;Cem Tremie
Non-Water Supply Well:
11 f` 13 rt• Bentonite Chil Tremie
ZMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft' ft.
13 55 #1 Sand Tremie
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,ha,dness,suilhu k typt,,gr.i.size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 1-26-22 Well ID# RW-110 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility IDt!(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No Cover a,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: AR 21 7022
(if'well field,one lat/long is sufficient)
35.415584 N -80.806876 w rt � ;i-:�:);� �-
Si nature of Cerlified Well Contractor W.1 U;,lrC�^•r.�-•,'wale;^"r-r'4�'(`I�,F'
yl�l. e t"itVLCJv:,JJ JI`Y I
6.Is(are)the well(s): [OPermanent or ❑Temporary K x / ! f- (1 ( )
HY.ci signing ihic orni, l hereby eerti v dun doe,cells it sere constructed in accordance
,with 15A NCA'02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cart•njthis record has been provided to the,cell owner.
//this is a repair,Jill out known well construction information and explain the nature of the
repair tinder 721 remarks.section or on the hack o/'this tarn,. 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.
1•or multiple injection or non-,raier ,supply wells ONLY with dre sane construction,Jon can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple,wells list all depths if aftllerenl(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
rater lerel is above taxi?/;,use 1617 Mail Service Center,Raleigh,NC 27699-1617
I
1.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: lit addition to sending the fonn to the address in
6 5/8 HSA & 2tt spoons24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the tollowing:
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 Center,Raleigh,NC 27699-1636
f
13a.Yield Method of test: 24c.For Water Supply&Injection Wells:
(gPm) Also submit one copy of this form Iwithin 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 of Environment and Natural Resources-Division of Water Resources Revised August 2013