GW1-2022-01356_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
We 11 Contractor Name 40 ft. 129 ft. Wet
3367 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells R O LINETHICKNER if a licable
FROM TO DIAMETER SS MATERIAL
Parratt-Wolff, Inc. ft. ft. ! in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 119 ft. 2 in. sch40 pvc
l,i.si all applicable well pertnity(i.e.County,.State,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 119 rt' 129 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt 111 I Portland Cem Tremie
Non-Water Supply Well:
111 rc 114.8 rr• Bentonite Chi Tremie
OMonitorine ❑Recovery
Injection Well: e• rt• Bentonite Chi Tremie
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 114 8 rr. 131.0 rt' #1Sand 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.
MW-4D ft. ft.
4.Date Well 11-12-21 s)Completed: Well ID#
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. JAN2 4 hF.
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 6"Aluminum Protective Cover
County Parcel Identification No.(PIN) 2'Concrete Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.414635 N -80.807941 W cilll ` a , \5 . �2(
Signature of Pitied Well CAbritractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary Hv signing d»s Jbrm, I hereby cern/v trim the trell(s)was(here)constructed in accordance
with 15A 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 EINo copy o/this record has been provided to the well owner.
/f'lhis is a repair,Jill out known well c•onstruc•lion information and explain the nature otthe
repair under 21 renrarkv section or on the back n/'this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
/•iu multiple injection or non-wafer supply wells ONLY with the same construction,you can
submit one Jortn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 129 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•in muhip/e wells list all depths ifdiJferent(example-3@200'and 2 @/00') construction to the following:
10.Static wit level below top of casing: 40 Division of Water Resources,urces,Information Processing Unit,
{t wafer/ere/is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY:'; In addition to sending the form to the address in
6 5/8 HSA 4" air rotary 24aabove. also submit a copy ofithis form within 30 days of completion of well
12.Well construction method: ° construction to the fallowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY-WELLS OiVY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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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