GW1-2022-04510_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, -
1.Well Contractor Information: k
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2973 tt• rt•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we OR LINER if a" •cable
FROM TO DIAMETER 1 THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compan)Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 4 in. sch40 PVC
List all applicable well permits(i.e.County.Slate,Variance,Injection.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT-SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 45 ft- 2 in.I .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ;; A
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 f` Portland Cem Tremie
Non-Water Supply Well:
M Monitorine ❑Recovery
6 ft. 8 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 I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8 ft' 45 ft' #1!Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRO,LING'LOG OttaWidditiona'1sieets if.necessa ,!-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gmin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
1-26-22 BB-2 ft. ft.
Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. i
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) pp �•a e
,r ci
14511 Huntersville-Concord Road, Huntersville, NC 28078 - `;
ft. ft.
Physical Address,City,and Zip 21t REMARKS x
Mecklenburg :•1 'r�J ttoS3 'i4'w '
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one[at/long is sufficient)
35.414378 N -80.805756 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Hv signing this firm, /hereby certiJv that the u•e//(c)leas(were)constructed in accordance
trilh l5A N('A('02('.0100 or l5A NCAC"02('.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
//this is a repair,Jill out known well c•onsiruc•rion information and explain the nature of the
repair under=21 reniarkv section or on the back of this Jorm. 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.
hbr multiple injection or non-iraier supply rrells ONLY frith the same construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple hells list all depths i/'di(lereni(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
flit ater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA construction to the followine: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Und 1.erground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form Iw thin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013