GW1-2022-09111_Well Construction - GW1_20220926

i
WELL CONSTRUCTION RECORD Pot Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRirpoN
Well Contractor Name 43 ft' 50 ft' I Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING.for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS nfATERIAI.
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 it. 20 ft. 2 i"' 1 SCh40 I PVC
List all applicable well permits(i.e.l•ounii,.State,Variance,Injection,etc.)
ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 e' 50 rr' 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft• 16 ft- Portland Cem Tremie
Non-Water Supply Well:
CaMonitoring ❑Recovery 16 ft• 18 ft• Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 it. 50 f�• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach`additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIPTION calor,hardness,soil/ruck type,mmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
f`' ft.
Date Well 7-28-22 s)Completed: Well ID# MW-09R
ft. ft.
5a.Well Location:
Colonial Pipeline Company rt. fr. SFP
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REDfARKS ✓....y
Mecklenburg 2 x 2 Pad
County Parcel Identification No.(PIN)
4"Pro Cover
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
35.414820 N -80.807029 w4.1 ",—A DQ g • (b • ZZ-
Signature of Certilied Well Contractor Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing dti.s irm, l herel,_v certt[V than the ire/l(s)was(were)constructed is accordance
with I5A NCAC 02C.0/00 or/SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
//this is a repair,fill out known well eanstruc•tion tnlnrnration and explain tire nature a/'the
repair under=2l remarks.section or an the hack o/'this/hrnr. 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 nurhiple injection or non-waier supply wells ONLY with the same construction,you can
.cuhmtt one jorni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this j form within 30 days of completion of wetl
I%ar nwhiple wells list all depths i/'di(/erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 43 (ft.) Division of Water Resources,Information Processing Unit,
I/traler 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 Corm to the address in
4 1/4 HSA & 2" spoons construction
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
13a.Yield m Method of test: 24c.For Water Supply&Injection[Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013