GW1-2022-00120_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD F i
or Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I '
Kevin White 14.WATER ZONES p I
FROM TO DESCRIPTION
Well Contractor Name ft. ft
i
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
FROM TO D.."gTER T THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DL4METER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 60 ft. 2 in. seh40 PVC
List all applicable well permits(i.e.CoranY,State,Mariance,hyection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS XI.ATERIAL
❑Agricultural ❑Municipal/Public 60 ft. 70 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. 56 fit- Portlandldpm Pour
Non-Water Supply Well:
fr. 58 rr. gentonite Chi Pour
oMonitoring ❑Recovery 56
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier 58 ft. 70 ft. #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 DESCRIPTION(color•hardness,soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
11-22-22 MW-104D k__ �t- �-­
�y
4.Date Well(s)Completed: Well ID# ft. ft. DE
L I
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. 1��tt ,;, ;I r'r ��31z"_na U:;i3
Facility/Owner Name Facility ID#(if applicable) .5gr'1.?J_N W
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft, ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitudeand Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatllong is sufficient) 22.Certification: >�
35.414319 N -80.806363 W !�J I
Signature of Certifie ell Contractor Date
6.Is(are)the well(s)t ©Permanent or ❑Temporary By signing this Jbrnt,1 hereby certify that the well(s)was(were)constructed in accordance
with LiA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy ofthis record has been provided to the well owner.
1J7his is a repair,fill out known ire/l construction information and explain the nature of the
repair under=21 remarks section or on the back oJ7his 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 hyection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple a elks list all depths if different(example-3 rr 200'and 2 cr 100') construction to the followlnz
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
//',rarer level is above casing,use"-" 1617 Mail Service Center;Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form widiin 30 days of completion of well
12.Well construction method: A construction to the following:
1i
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent.r,Raleigh,NC 27699-1636
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection Wells:
i
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health diepartment of the county where
constructed.
Fort GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013