GW1-2022-04506_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a tics hle
FROM I TO I DIAMETERI THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ` in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop) _
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8.5 fit. 4 in. sch40 PVC
List all applicable well perintts(i.e.County.State, I%ariance.lnjeclion,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 8.5 ft' 33.5 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Com mere ial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 4.5 rt. Portland Cem Tremie
Non-Water Supply Well:
El Mon itori ng ❑Recovery
4.5 ft. 6.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifaimliciblel
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 6.5 ft. 33.5 ff #1;Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. "'
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❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach.ad'ditionild sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-30-22 Well ID# BA-5
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. rt. ,,'. ,n`T ti� •Y^I,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 a 9 2029
Physical Address,City,and Zip
21.REMARKS
Mecklenburg ,
u.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one]at/long is sufficient)
35.414269 N -80.806101 W 1�5
Signature ofCertitied Well Contractor - Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this/orin, I hereby c•era/v that the trell(+)was(were)constructed in accordance
with I SA NCAC 02C.0100 or/SA NCAC 02C.0100 Well Consvruchon Standards and that a
7.Is this a repair to an existing well: ❑Yes or EI No copy aJ'this record has been provided to the well owner.
4 this is a repair,Jill out known well construction information and explain the nature ofihe
repair under,2l remarks section or on the back oJ'llus,l rat. 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.
h'or mulliple injection or non-❑aler.supply wells ONLY with the same construction,you can
suhniii one Jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 33.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For niuhtple a ells Its/all depths iJ'diJferent(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: Dry Division of Water Resoa'rces,Information Processing Unit,
y'uaier level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In 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 Ceiter,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy Of this form1within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county heal h department of the county where
constructed. I.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013