GW1-2022-04513_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
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 livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR.TUBING a eothermal closed-loop
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft' in•
0 34 2 sch40 pvc
List all applicable hell pernotc(i.e.C oun(v.State,Variance,hyection,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 34 ft- 54 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 80 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
30 ft- 32 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK:if a' licalile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
32 ft- 54 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRR LING LOG;(attach:addidonahsheeti'if nicema
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUmck type,train size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
1-31-22 MW-7R ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft. i
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft ft
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
M
Physical Address,City,and Zip 21.REMARKS I
Mecklenburg
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)
35.415100 N -80.806249 W � � ✓� -(�- a�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing this form, l hereby certify that the we/l(s)was(were)constructed in accordance
u,uh l SA 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 ofthis record has been provided to the we//owner.
/f this is a repair,till out known well construction information and explain the nature of the
repair under 21 remarks section or on the back ofthis firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fir unuhiple injection or non-water supply wens ONLY with the same construction,van can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 54 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferem(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
Iflraler/eve/is above casing,use-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: hi addition to sending the form to the address in
24a above, also submit a copy of thiis for n 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 Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
IgP ) Also submit one copy of this form Iwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health'department of the county where
constructed.
I'm ni GW-I North Carolina Department of Environment and Natural Resources—Division of Water Res I utces Revised August 2013
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