GW1-2022-01350_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY:
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 45 ft' I Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we11s O LINER if a licable
FROM TO DIAMETER R THICKNESSI MATERIAL
Parratt-Wolff, Inc. ft. ft. I I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f� 10 ft 4 in. sch40 pvc
List all applicable well permits(i.e.C'ountu Slate, 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 10 f`' 45 ft' 4 '"' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 7 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitorina ❑Recovery fL 9 f`' Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1" ft.
9 45 #11Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addition iil sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilimck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) J ft. ft.
ft. ft.
4.Date Well(s)Completed: 12-15-21 Well ID# RW-102
ft. ft.
5a.Well Location: ft. ft. ice"
Colonial Pipeline Company ft. ft. JAN
Facility/Owner Name Facility IDk(if applicable) --
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS Ji
Mecklenburg No Cover
County Parcel Identification No.(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one[at/long is sufficient)
35.414663 N, -80.806420 W.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary Hv signing this form, 1 hereby certify thgl the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oJlhis record has been provided to the ive//owner.
tf this is a repair.Jill out known well construction information and explain the nature oJ7he
repair under 121 remarks.section or on the back o/'this form. 23.Site diagram or additional well details:
You may use the back of this page Ito 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 injection or non-wafer supply wells ONLY with the same construction,you can
.submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list al/depths iij'dtffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 4 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA & 2t� spoons construction
above, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: i
Also submit one copy of this form within 30 days ofcompletion 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
I