GW1-2022-01349_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 31 fr. 59 ft. Wet
2973 ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for mWti-cased wellsOR LINR f a lcable
IETE THIESFROM R MATERIAL
Parratt-Wolff, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 14 ft. 4 '"' sch40 PVC
List all applicable a-ell permits(i.e.CottNv,Stale, Variance,hrjeclion,etc.)
ft. fL i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
14 f` 59 f` 4 '"'' .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. "•
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f3. 10 1 Portland Cem Tremie
Non-Water Supply Well:
10 ft 12 ft- Bentonite Chil Tremie
ZMonitoring ❑Recovery
Injection Well: ft. ft.
Cl Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
12 59 #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/mck type,grain siu etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 12-16-21 RW-103 s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID!!(ifapplicable) y
ft. ft. --
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. fr.
Physical Address,City,and Zip 21 REMARKS o
Mecklenburg No Cover`
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.414359 N -80.805447 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this form,I hereby certify drat the wehts)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C onsiruclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZJNo copy oflhis record has been prorided to the well owner.
1/7his is a repair,fill our known well construction injornnalion and explain the nature ofrhe
repair under 21 remarks section or on the back oJ'ihis 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 inieclion or non-waler supply wells ONI Y with the same construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 59 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For mahiple we/Is list all depths fdiflerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Res roes,Information Processing Unit,
4 water level is above casing,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
„ 24a above, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: 6 5/8 HSA , & 2 Spoons construction to the tollowiruz
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,JUnderground 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
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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