GW1-2022-03665_Well Construction - GW1_20220321

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 30 ff. 47 ft. s Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING(for multl-cased wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MA'fERIAI.
Parratt-Wolff, Inc. ft. ft. tin.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 22 R• 4 in. seh40 PVC
Lai all applicable well pernins(i.e.(•oun(v,,State,Variance,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 22 ft' 47 f" 4 in.
.010 sch40 PVC
f. ft. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTME'1'HOD&AMOUNT
❑lrri ation 0 fr. 18 ft. Portland'Cem Tremie
Non-Water Supply Well:
Rl Monitoring ❑Recovers_'
18 ft. 20 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 20 rr' 47 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fr. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional iheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eolor,hardness,soith ochtype,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) R. ft.
ft. rr.
4.Date Well(s)Completed: 1-28-22 Well ID# RW-1 11
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. a P,r 7 ?I�..r-
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/Ion g is sufficient) \1
35.413867 N -80.806700 N, �-
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this.1brm,I herebv cerq&that the well(+) was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well r•onslructiun Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy o/thi.s record has been provided to the irell owner.
I/'Ihis is a repair,,Jill out known well construction information and explain the nature o/the
repair under-21 remarks.section or on the back a/This/orm. 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.
hor multiple injection or non-crater supply irons ONLY irate the.+ante construction,you can
submit oneJornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 47 (ft.) 24a. For All Wells: Submit this fixm within 30 days of completion of well
1-'or multiple wells list all depths tJ'diJferem(example-3«200,and 2 a,l00,) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
IJ water level is above casing,use•' " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: It I addition to sending the form to the address in
6 5/8 HSA & 2" spoons 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.l
Division of Water Resources,L)nllerground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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. 1
Form GW-I North Carolina Department of Environnient and Natural Resources—Division of Water Resources Revised August 2013