GW1-2022-04503_Well Construction - GW1_20220509

i
WELL CONSTRUCTION RECORD i
For Internal Use ONLY: I This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
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 bcable
FROM TO DIAMETER{ THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING ebthermal closed-loop)
FROM TO DIAMETER THICKNESS f MATERIAL
2.Well Construction Permit#: 0 ft. 22 ft. 4 in. sch40 PVC
List all applicable ire/l permits(i.e.Couv(y,Stale, 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' 42 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in,
❑Industrial/Com mere ial ❑Residential Water Supply(shared) 18.GROUT ;
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑lrri ation 0 tr. 17 It. Portland Cem Tremie
Non-Water Supply Well:
17 rt. 19 rt. Bentonite Chi Tremie
(�Manitorine ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa'"licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
19 ft- 42 fr• #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attitch=addidoniil sheets if.necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grainsim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-18-22 Well ID# BA-2
ft. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. ft. MAY
•-
Physical Address,City,and Zip
'-21..REMARKS
Mecklenburg ;%4
County Parcel Identification No.(PIN) 1.�"'"�t�'�-�jj"'•`• '.t'a'�- "�`
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient)
35.414387 N -80.805917 W \&-AeA-A-� 1 .�_ zZ
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this/hrm, I hereby cerli&thai the we//(c)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 102C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZINo copy o(this record has been provided to(lie well owner.
tfdus is a repair,ji//out known well construction in/orntation and explain the nature of the
repair under'21 remarks section or on the back of'dti.s jbrm. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS I
9.Total well depth below land surface: 42 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we//s list all depths ij'dii ferew(example-3@200'and 2 u/00') construction t0 the following'
10.Static water level below top of casing: Dry (ft.) Division of Water Resou I rces,Information Processing Unit,
l/*water level is above casing,use"-" 1617 Mail Service Ce i ter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Infection Wells ONLY': In addition to sending the form to the address in
HSA 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.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: Amount: well construction to the county health;department of the county where
constructed. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Res ources Revised August 2013