GW1-2022-04492_Well Construction - GW1_20220509

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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
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FROM TO DESCRIPTION
Well Contractor Name ft. ft.
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. & ft. I
i in.
Company Name 16.INNER CASING OR TUBING` eothermal`dosed-loo ..
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 9 fr. 4 in. seh40 PVC
List all applicable well permits(i.e.County,Stale, Kariance,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 9 f`' 24 fr' 2 in. 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 rr. 5 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
5 ft. 7 ft, Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK':if a Hcable,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 7 ft- 24 ft. #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.'DRILLING:LOG.attach addiiionali'sheefs;if;necessa ? ..,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilimck type,grain size,etc...
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
2-10-22 BB-8 ft. fr.
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft.
Physical Address,City,and Zip
�21.3tEM.1RKS' '! aM,� :`,�,•-
Mecklenburg -
County Parcel Identification No.(PIN) `..,5.,, n,�i •�,j.l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field one[at/long is sufficient)
35.413856 N -80.806315 W ��
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By.signing this form, 1 hereh_v certtfp that the we/1(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copy gflhis record has been provided to the well owner.
Ijihis is a repair,Jill out known well consiruclion information and explain the nature of the
repair under-21 remarks section or on the back q/1his form. 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.
For muhip/e injection or non-water supply wells ONLY with the same construction,you can '
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/ds list all depths ifdifJereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Dry Division of Water Resources,Information Processing Unit,
1f u•aler level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA 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 Center,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: Amour[ well construction to the county health;department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013