GW1-2022-01360_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY: V
This form can be used for single or multiple wells
L Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 40 r`• 70.5 f`' P Wet
2973 f`• If` j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 e. 4 i" SCh40 I PVC
List all applicable well permits(i.e.CounlY.Stare, 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 20 tt. 55 ft. 4 in. .010 sch40 PVC
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) j
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 16 ft. Portland Cem Tremie
Non-Water Supply Well:
16 ft- 18 ft Bentonite Chil Tremie
MMonitoring ❑Recovers
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
18 55 #11Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additiondl sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,girain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
11-24-21 RW-95 f`' f`'
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Colonial Pipeline Company ft. ft. { (l\ I .f
Facility/Owner Name Facility ID#(if applicable) ft. ft. ^'J
14511 Huntersville-Concord Road, Huntersville, NC 28078 4 ��'�
ft. ft.
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:
(ifwell field,one lat/long is sufficient)
35.414861 N -80.805365 w ��� �� (� d 7- 1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing/his/brm,1 herebv certify that the trellis)was(were)constructed in accordance
wuh 15A NCAC 02C.0100 or 15A NCAG 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ojthis record has been provided to the we//owner.
U this is a repair,fill out known well construction information and explain the nature ol'the
repair under=21 remarks section or on the back a(lhis./brm. 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.
Fnr multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple ire/is list aN depths tfdi/fereni(example-3@100'and 2@ 100') construction to the following:
10.Static water level below top of casing: 32 Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Ce nter,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•t SpOOnS 24a 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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