GW1-2022-04507_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD i
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
ft. ft.
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased�.weHs LINER if S lichble
FROM TO DIAMETEIII THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. rt.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop) _
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 6 rt. 1 4 '^ SCh40 PVC
list all applicable well permits(i.e.Countyy,Stale, Variance,Injection,etc.)
ft. It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6 It' 36 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. i^•'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT is y_a W
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 2 ft. Portland Cem Tremie
Non-Water Supply Well:
2 fr. 4 fr. Bentonite Chii Tremie
OMonitorine ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remedia[ion 19.SAND/GRAVEL PACK ifa 1icable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 36 ft. #1�Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING'LOGattkh',2dditionilsheetsif^ee6si " .4L
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-27-22 Well ID# BA-6 ..�
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. zU _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ';^
ft. ft.
Physical Address,City,and Zip 2l.REMARKS f.
Mecklenburg
County Parcel Identification No.(PIN)
I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one[at/long is sufficient)
35.414229 N -80.806201 W �.�� 0
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv.signing lhis Dorm, I herehv cert/Jy that the we//(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gflhis record has heen provided to the well owner.
4 this is a repair,fill out known well construction information and explain the nature of'the
repair under<21 remarks section or on the hack q{'this 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.
hor multiple injection or non-water supply wets ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/'or multiple wells list all depths iJ'difPrem(example-9@200'and 2@100') construction to the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
/)water level is shove 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county healh idepartment of the county where
iconstructed. ps
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013