GW1-2022-01363_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 ESCRIPTION
Well Contractor Name ft. ft.
2973 ft. I ft. 4
NC Well Contractor Certification Number 15.OUTER CASING for mW&cased ovens OR LINER if a Geable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. o ft. 90 rt' 14 j Srh40 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 f` 116 12 nn' 1 SCh40 I PVC
List all applicable well permits(i.e.C'ouniv,State,Martance,Injection,etc.)
ft. I ft. i in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 116 r`' 126 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. e. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 109 ft- Portland Cem Tremie
Non-Water Supply Well:
109 f` 112 ft- Bentonite Chi e Tremi
MMonitoring ❑Recovery
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
112 ft• 133 f`• #1?Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addiNondF sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilimck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
11/9/-21 MW-97D
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID4(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. ft.
Physical Address,City,and Zip
21.REMARKS :1 ',-
Mecklenburg 6"Alu'minum Cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one Iat/long is sufficient)
35.415614 N -80.805674 w -& g ( a -
Sign• re ot'Certified Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary yv signing this/brm,l herebv certi/v that the well(,)vas(were)constructed in accordance
Willi 15A NCAC 02C.0100 or I5A NCAC 02C.0100 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 we//owner.
1/7hts is a repair,Jill out known well construction information and explain the nature ofilne
repair under=21 remarks section or on the back q/'this/orm. 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.
For multiple injection or non-water supply wells ONLY with die same construction,volt can
subina one form. SUBMITTAL INSTUCTIONS
I
9.Total well depth below land surface: 126 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nmlliple wells list all depths if ch#erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resoi rces,Information Processing Unit,
(/'water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: �ln addition to sending the form to the address in
24a above, also submit a copy of,this form within 30 days of completion of Well
6 Sl8 NSA 8 6'Air Hammer.<'PVC Casing,3 7/a'Air Hammer.2'PVC well 12.Well construction method: construction to the following: 1
(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 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i
I