GW1-2022-04498_Well Construction - GW1_20220509

1
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. �
2973 ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIAMETERTHICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I R.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 15 ft. 2 i" sch40 PVC
Li.ci all applicable well perinns(i.e.Couniv,Stale,Variance.injection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Nell' FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 50 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 11 ft- Portland Cem Tremie
Non-Water Supply Well:
RlMonitoring ❑Recover\ 11 ft. 13 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK"(if a"'ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft MATERIAL EMPLACEMENT METHOD
13 ft' 50 #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additiona 7sheets if nice ssa"-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 1-24-22 s)Completed: Well ID# MW-37R ft. ft.
ft. ft.
5a.Well Location: _
Colonial Pipeline Company ft. ft. ¢ r 31 ,.f J
Facility/Owner Name Facility IDII(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip 21.REMARKS f, ura ELi 7
Mecklenburg
County Parcel Identification No.(PIN) 'Y''' "' °'• �
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one lat/long is sufficient)
35.415118 N -80.806688 W a a aQ a a-
Signature ot'Cenitied Well Contractor A Date
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this./orm, I herebv cerii/i'ihai,lhe well(,) was(here)constructed in accordance
irith 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 ONo copy of this record has been provided to the we//owner.
IJ'this is a repair,Jill out known well construction in/brmation and explain the nature of the
repair under.-21 remarks section or on the back g11his 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 multiple injection or non-water supp/v wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 24a. For All Wells: Submit this form within 30 days of completion of well
!•br multiple we/Is list a/1 depdas ijdiJJerent(example-3@200'and 2 a,100') construction to the following:
10.Static water level below top of casing: Dry Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: Ini addition to sending the form to the address in
24a above, 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 Cen ier{Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: t Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Fornn GW-1 North Carolina Department of Environnnent and Natural Resources-Division of Water Resources Revised August 2013