GW1-2022-01351_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 30 ft. 52 rt. E Wet
2973 ft. ft. p
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING(geothermal closeddoo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 12 ft- 4 in- SCh40 PVC
List all applicable well permits(i.e.Coun(v,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12 ft. 52 ft. 4 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
El Inn gation 0 ft. 5 ft. Portland Cem Tremie
Non-Water Supply Well:
5 ft. 7 sr• Bentoriite Chi Tremie
ZMonitoring ❑Recovery
[njection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
7 rt. 52 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG attach addihon'al sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Rewm) El Other(explain under 421 Remarks) ft. ft.
12-14-21 RW-101 rt. rt.
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. I t
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 2'
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
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: (�
(if well field.one[at/long is sufficient) W k
35.414656 N -80.806521 W
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
By signing this form,I hereby certify that the irell(s)vas(mere)constructed in accordance
ivah 15A NCAC 02C.0100 or 15A NCAe'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
!/this is a repair/ill out known nrell construction information and explain the nature gJ7he
repair under 721 remarks.section or on the back o/'thisJarm. 23.Site diagram or additional well details:
You may use the back of this pageto provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hbr multiple injection or non-water supply wells ONLY nrah the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 52 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,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 Infection Wells ONLY: !In addition to sending the form to the address in
6 5/8 HSA & 2" spoons24a 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,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
For Water Supply Water Supply&Injection Wells:
13a.Yield(gpm) Method of test 24c. r
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. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water R E esources Revised August 2013
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