GW1-2022-03257_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD f
For Internal Use ONLY: l
This form can be used for single or multiple wells
I.Well Contractor Information:
Anthony Convery 14•WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. j
4343
NC Well Contractor Certification Number 15.OUTER CASING.for multi,cased wells OR LINER SS ff a licable
FROM TO DIAMFTER ; THICKNE MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING fileofliermall closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 6 rr. 4 in. sch40 PVC
Li.wt an applicable well permits(i.e.Cownv. ';late,Variance,hyection,eat)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN t;
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 6 ft- 36 ft• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPL.ACEMEN'I METHOD&AMOUNT
❑Irrigation 0 13 2.5 rt• Portland Cem Tremie
Nun-Water Supply Well:
Monitoring ❑Recovery
2.5 rt. 4 rt. Bentonite Chii Tremie
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
4 rt 36 ft #1 Sand Tremie
❑Aquifer"test ❑Stormwater Drainage rt. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional's`heets if necessary)
❑Geothennal(Closed Loop) ❑"'racer FROM TO DESCRIPTION calm,ha.Al ss,suilhvck t he,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 1-26-2 Well ID#AC-6
5a.Well Location: rt. ft. 1'
Colonial Pipeline Company rt. I ft. MAR 1 4 202?
Facility/Owner Name Facility ID#(if applicable)
rt. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip r •., .,.r ,
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if\well field,one[at/long is sufficient)
35.414457 N -80.806531 W �-
Signatureof•Certified Wet ontractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy.signing;This/oi cert/V ihnt rile well(,)was(were)construclet/in accordance
With 15A Nt•At'02C.0100 or 15A N'AC 02C.0200 Well Construction Standards coal that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ollhis record has been provided a,the:well corner.
//this is a repair,fill out known well construction in/nrineuion and explain the nnlure oflhe
repair under 21 remarks sec lion or on the hack of this/nrnh. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
ror nuhiple injection or non-water supply wells ONLY with the sane construction,You can
subna one/brn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hLr nulliple wells lisi all elepib.s ifdillerenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Unknown (ft) Division of Water Resources;Information Processing Unit,
4 water lehel is above caving,use" 1617 Mail Service Center,;Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: fit/addition to sending the lurm to the address in
HSA w/ Geoprobe 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,Illiderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centetr,iRaleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form within 30 daysofconlpletion 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