GW1-2022-01357_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:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft' 50 ft I Wet
2973 ft. ft.
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. rt. I
in.
Compan}Name 16.INNER CASING OR TUBING(geothermal elosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 25 ft- 4 r"' 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 f`' 50 ft' 4 '"'' .010 sch40 pvC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.i
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 21 it Portland Cem Tremie
Non-Water Supply Well:
RlMonitoring ❑Recovery 21 ft• 23 ft• Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
23 ft• 50 ft. #1;Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '
20.DRILLING LOG attach addilionil sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well 12-6-21 RW-98s)Completed: Well ID# tt. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 2
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. a.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg No cover '. I
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one[at/long is sufficient)
35.414937 N -80.805322 W
Signailtire of Cert tied Well Co ac or �� Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this.farm, I hereby certi%v that the well(s) vas(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/7his record has been provided to the well owner.
(/'this is a repair,till out known well construction inlorntation and explain the nature of due
repair under:-21 remarks.section or on the back qj this Jbrnu. 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 injection or non-water supply wells ONLY with the same construction,you can ,.
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 24a. For All Wells: Submit this form within 30 days of completion of well
For mahiple we/A list all depths ifdiJferem(example-3 tr,200'and 2 to 100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
//'water lerel is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY:1 In addition to sending the form to the address in
„ 24a above, also submit a copy of jthis form within 30 days of completion of well
12.Well construction method: 6 5/8 HSA , & 2 Spoons 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&Injection Wells:
s 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.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013