GW1-2022-03256_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used fbi single or multiple wells
1.Well Contractor Information: ;
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft• 32 ft. I Wet
2973 ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING((for multi cased wells OR LINER if a 1icab►e
FROM TO DIAMETER THICKNESS MA'I'EHIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING edthermal closed-loop)
FROM TO DIAMFTER THICKNESS MATERIAL it
2.Well Construction Permit#: 0 ft. 7 R. 4 in. sch40 PVC
List all applicahle well permits(i.e.Couniv,Slate,Variance,injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): I SCREEN li
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 ft' 32 ft. 4 in.
.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS:GROUT i
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑lrri ation 0 rt. 3 rt. Portland Cem Tremie
Nun-Water Supply Well:
MMonitoring ❑Recovery 3 rt. 5 e. Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19..SAND/GRAVEL PACK if a"` licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 5 fr. 32 rt. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'(atfilit 4ddifionalisheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM 1'D DESCRIPTION lcolar.hardness,soil/rucktype, -in size,etc.
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) ft. R.
ft. ft.
4.Date Well(s)Completed- 1-12-22 well ID# RW-106
ff. rt.
Sa.Well Location:
Colonial Pipeline Company ft. ft. r r;
Facility/Owner Name Facility IDk(ifapplicable) - --
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
r Physical Address,City,and Zip 21.REMARKS t
Mecklenburg N6,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)
35.414615 N -80.806221 N; a-
��
Signature ofCdertified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary .f 11 O ( )
H+signingihi.r orn;l hereby ceni +Choi the ire//s tru.r were evwstructed in accordance
frith 15A NCAC 02C.0100 or 15A NCAC 62C.020t1 Well Co nsirucliun Slundurds and that a
7.Is this a repair to an existing well: ❑Yes or EINo cony o/'ihts record has been provider/to ihe'orell owner.
if this is a repair,Jill out known well construction information and explain the nature of the I
repair under"21 remarks section or on the hack q/lhi.s,/Arun,. 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.
1,ihr nnulliple injection or non-tyuler supply ire/A ONLY utth the sane construction,you can
suhn/l one fern. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 31 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or nudtiple ire//s fist all depths i/'d///erent(example-3@200'and 20100') construction t0 the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
if water sere/it above c•aying,use" 1617 Mail Service Center,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 & 2i� spoons construction
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the tollowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,U ii1derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 daysufcompletionof
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