GW1-2022-00118_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White .,14.WATERZONES.
FROM, TO DESCRIPTION
Well Contractor Name- ft. ft.
2973 ft. ft.
r
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable FROM TO DIAMETER THICKNESS MATERIAL
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 ft. 100 ft' 2 ! t"' SCh40 PVC
List all applicable trell permits(i.e.County,Slate;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 100 ft- 110 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
❑Irrigation 0 ft. 96 ft. PortlanI Cem Pour
Non-Water Supply Well: ,
2Monitoring ❑Recovery gg ft. g8 ft. Bentonite Chil Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLf,L EMPLACEMENT METHOD
98 ft. 110 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOGattach additional sheets if necessa
❑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.
--
4.Date Well 11-21-22 MW-108D s)Completed: .Well ID# f[. ft. Dr .t �
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
r-a as
Facility/Owner Name Facility ID#(if applicable) f[. ft. J'"•''�
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft ft
Physical Address,City,and Zip
21:REMARKS
Mecklenburg
County Parcel Identification No.(PIN) i I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.415329 . N -80.806049 W 'pZ a-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this Jbrm, I hereby certify that the n,ell(s)Bras(were)constructed in accordance
ivith LiA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
/fthis is a repair,fill out knotrn trel/construction ihJormation and explain the nature oJ•the
repair under�'21 remarks section or on the back,ofthis 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 h jection or non-water supply trells ONLY with the same construction,you can
submit one form. . SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 110 (ft.) 24a, For All Wells: Submit this,'form within 30 days of completion of well
For multiple trells list all depths ifdii ferent(example-3 n 200'and 2@100') construction to the following: l
10.Static water level below top of casing: (ft.) Division of Water Resources,rces,Information Processing Unit,
Y'ivaler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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 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
I
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
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j!
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013