GW1-2022-01362_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD For Internal Use ONLY: y
This form can be used for single or multiple wells
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1.Well Contractor Information: ;
Kevin White 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 31 ft' 44 ft. I Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER ifa licable
FROM TO DIAMETER THICKNESS hATERIAL
Parratt-Wolff, Inc. ft. ft. ; in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 14 ft. 4 t" Sch40 pvc
List all applicable well pernrits(i.e.Coun(Y.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 14 ft- 44 ff 4 '"' .010 SCh40 pvc
❑Geothermal ) ❑Residential Water Su (single) ft. ft.
(Heating/Cooling Su PPIY PPIY
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 10 1 Portland Cem Tremie
Non-Water Supply Well:
IZJMonitoring ❑Recovery 10 ft. 12 ft• Bentonte Chi Tremie
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.
12 59 #1 Sand Tremie
❑Aquifer Test ❑S[ormwater 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/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 12-20-21 Well ID# RW-104
ft. ft
5a.Well Location: ft. ft.
Colonial Pipeline Company
JAN 2 4 _ t,
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. ft.
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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: p\\
(if well field one lat/long is sufficient)
35.414719 N -80.806525 W
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): (01permanent or ❑Temporary By signing this./brie,1 hereby certify that the we/l(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 EINo copy ofthis record has been provided to the well owner
ljthis is a repair/ill 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 of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Pur muhiple ijecrion or non-waler supply wells ONLY with the same construction,you c•an
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 44 24a. For All Wells: Submit this'form within 30 days of completion of well
For nudGple wells list all depths ifdifferem(example-3 ct 200'and 2@100') construction to the following:
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10.Static water level below top of casing: 31 Division of Water Resources,Information Processing Unit,
g'ivater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In,'addition to sending the form to the address in
6 5/8 HSA & 2" spoons construction
above, also submit a copy of this form Within 30 days of completion of well
12.Well construction method: ° construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,ltindetground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection,Wells:
13a.Yield(gpm) Method of test: I
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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