GW1-2022-00119_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.NVATER'ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING for molt.-cased wells OR LINER,it a Gcable
FROM TO DIAMETER THICKNESS DATERIAL
Parratt-Wolff, Inc. ft. fr. . in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 61 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,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 61 1" 76 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri scion 0 fr. 57 ft- Portland Cem Pour
Non-Water Supply Well:
Monitoring ❑Recovery
57 ft. 59 It- Bentonite Chil Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO 111ATERIAI. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier 59 fr' 76 ft. #1 Sand Tremie
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/mck type.gnin size,etc.
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 11-21-22 WellID# MW-103D rt. ft.
a=
5a.Well Location: 7
ft. ft. _ 1
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Una
14511 Huntersville-Concord Road, Huntersville, NC 28078 OG
ft. fr.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latilong is sufficient)
35.414170 N. -80.806561 W la ll �Z
SigSig a�Certttied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NC AC 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 oJ'this record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back ofthis ford. 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 oyection or non-waler supply wells ONLY with the sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 76 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii(Vi ferent(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
IJ'water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (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: HSA construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: ,
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount:
well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department ofEnvironnrent and Natural Resources-Division of Water Resources Revised August 2013
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