GW1-2022-01361_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:
Gary Ellingworth 1R.WATERzoNEs
FROM TO DESCRIPTION
Well Contractor Name 40 rr 70.5 ft' wet
3367
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. rt. ft. Iin.
Company Name 16.INNER CASING OR TUBING eothermal closed-loci
WR0300120 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:List all applicable well permits(i.e.Count,State, D'artance,Injection,etc.)) 0 ft. 20 ft- 4 i" SCh40 PVC
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 ft- 70.5 f- 4 in. j .010 Sch40 PVC
ft. r. in.
❑Geothermal(Heatin /C00lin Supply) ❑Residential Water SuPPIY(single) I
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
El Irrigation 0 fr. 16 ft- Portland Cem Tremie
Non-Water Supply Well:
16 rr. 18 rr. gentonite Chi Tremie
12]Monitoring ❑Recovery
Injection Well: fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
18 fr 70.5 rt• #1,Sand Tremie
❑Aquifer Test ❑Stormwater Drainage rr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft, ft.
4.Date Well(s)Completed: 11-22-21 Well ID# RW-94
1
5a.Well Location: ft. ft.
Colonial Pipeline Company rt. ft. H
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 .-A
ft. ft. 1„
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[at/long is sufficient)
35.415969 N -80.805402 W ,9AI O(2. \A old '01�
Signature o)Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form, I hereby certify that the ire//(s)was(were)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 ONo copy o/this record has been provided to the cell owner.
4 this is a repair,Jill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back of this form. 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submh one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70•5 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For nmhiple wells list al/depths t/dtfferenl(example-3 tt 200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 40 (ft-) Division of Water Resources,Information Processing Unit,
11'water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 4 (in.) 24b. For Iniection Wells ONLY:1 In addition to sending the form to the address in
6 5/8 HSA , 4" PVC, &2�� 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.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C'nter,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 ofcomple[ionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Fort»GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013