GW1-2022-01348_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fbrm can be used for single or multiple wells
I.Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION,
Well Contractor Name 40 ft. 70,5 ft. I Wet
3367 ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for mWti-cased wells OR LINER if a licable
FROM TO DIAMETERI 'THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ;in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WR0300120 FROM TO DIAMETERI THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 20 It- 4 Mtn' SCh40 pvc
Lisl all applicable+cell permits(i.e.Coun(v,Stale,Variance,hrjec•lion,etc.)
ft. ft. :in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft- 70.5 ft. 4 in. .010 Sch40 pvc
❑Geothermal(Fleatin /Conlin Supply) ❑Residential Water Supply(single) ft. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h'ri ation 0 rt. 16 ft. Portland;Cem Tremie
Non-Water Supply Well:
ZMonitoring ❑Recovery 16 e. 18 fr. Bentonite Chii Tremie
Injection Well: ft. ft. �i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLALEM ENT METHOD
18 fr• 70.5 Ir• #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/ruck type,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
11-22-21 RW-94 It. It. l t
-<•
4.Date Well(s)Completed: Well ID# Ir. It. t
5a.Well Location: ft. R. JAN 2 4 2�f
Colonial Pipeline Company
Facility/Owner Name Facility IDH(if applicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 '
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well field,one lat/long is sufficient)
35.415969 N -80.805402 W 01( la
Signature of pitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary g /
Hv signing this ornt,l hereby c•ern v that the well(� m s us mere constructed in uccurdwrce
mill/SA NCAC 02C.0/00 or I5A NCAC 102C.0200 Well Conviruction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy q/this record has been provided to the we//owner.
1lthis is a repair,fill oat known well construction information and explain the nature ofthe
repair under=2/remarks sec lion or on the hack o/'this 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.
bor maniple ityeeltnn or non-maler supply melh ONLY wah the.came construcrion,you call
suhiva one.jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70•5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bor tun/liple wells fist all deplrc if dillerent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
It ivaler level is above caving,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA , 4" PVC, & 2" S OOC1S 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p 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(gpm) Method of test: 24c.For Water Supply&InjectioniWells:
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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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