GW1-2022-04515_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
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4.WATER ZONES is
K@VI11 White FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING' for multi-cased wells OR LINER if.a Hcable.
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING,OR TUBING(ee&thermal'closed-Loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 118.5 ft• 4 in. sCh40 PVC
List all applicable hell permits(i.e.Countyt State, Variance,Injection,etc.)
ft. I fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18.5 ft- 43.5 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fr. 14 t" Portland Cem Tremie
Non-Water Supply Well:
[?]Monitoring ❑Recovery
14 ft- 16.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK:ifs licable
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 16.5 ft• 43.5 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft. i
❑Experimental Technology ❑Subsidence Control '
20:DRILLING tiOC attach+addifiotalisheets;ifaKcessa «t �.v�,,,�-� ,4,,,�4.;:.•
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-28-22 well ID# BC-6 fr. fr.
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5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. _
Facility/Owner Name Facility ID#(ifapplieable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr. MAY 0 9 202?
Physical Address,City,and Zip 21.REMARKS' s
Mecklenburg t lei
County Parcel Identification No.(PIN) 1i +•?srtit5:ti f�irB E'i-i1',;L.••3;:C..'.: i•'�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
617well field.one[at/long is sufficient)
35.413743 N -80.805872 W
Signature ot'Cer itied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary y g /. v (J
13 signing this' orm, /hereb certi thatahe u�eN s vas here constructed in accordance
with I5A NCAC 02('.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copv o/lhis record has been provided to the we11 owner.
/'this is a repair,Jill out known well construction information and explain the nature of1he I
repair under=21 remarks section or on the back o/'this%arm. 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 nudurple injection or non-water supply we/h ONLY with the same construction,you can ,
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 43.5 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi#&rent(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,
4 water level is above casing,use"-" 1617 Mail Service Ceiter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of thlis',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.) r
Division of Water Resources,UInderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form1within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environmcnt and Natural Resources-Division of Water Res�l urces Revised August 2013
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