GW1-2022-04514_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal use oNLv:
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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased�weIts OR LINER.if s ►icable'
FROM TO DIAMETER i THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. n.
Companc Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 17 ft. 4 in. SCh40 PVC
Ow all applicable well pernins(i.e.Counfv,Stale, Variance,Injection,etc)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17 {c 37 {t, 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt• 13 ft. Portland Cem Tremie
Non-Water Supply Well:
0 Monitorine ❑Recovery
13 ft. 14.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK"if a licable
FROM TO MATERIAL EMPLACEMENT METHOD.
❑Aquifer Storage and Recovery ❑Salinity Barrier 14.5 ft' 37 {t, #1-:Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach addiftonil`sbeets:if;necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type.gmin sim,etc.
❑Geothermal(Heating/Cooline Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 2-18-22 Well ID# 813-9
ft. ft.
ft. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
2I:REMARKS I<'
Mecklenburg - try
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell fiel&one lat/long is sufficient) I� . -
35.413669 N -80.806272 w
Signature ofCeilified Well Contractor Date
6.1s(are)the well(s): ❑Permanent or ❑Temporary BY,signing this farm,1 herebv certt[v that the ire//(s) was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gjthis record has been provided to the ire/l owner.
/(this is a repair,Jill out known well construction information and explain the nature q/the
repair under'21 remarks section or on the back 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
Far muhiple hells list all depths if different(example-3@200'and 2 a 100') consWction t0 the f011OwinH:
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10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
//rater level is above casing,use"-" 1617 Mail Service Cc 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: F ISA construction to the following:
(i.e.auger,rotarv.cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cep ter,Raleigh,NC 27699-1636
13a.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 healthidepartment of the county where
constructed. +ki
Form GW-I North Carolina Department of Environment and Natural Resources-Division o('Water Resources Revised August 2013
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