GW1-2022-03261_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
t
Anthony Convery 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4343 ft. ft.
NC Well Contractor Certification Number 150UT£R CASINGa for,molti-cased wells`ORLINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name I6.INNER CASING,OR TUBING;°eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fL 9.5 ft. 4 tn• sch40 PVC
List all applicable well perntils(i.e.County,Slate, Variance,injection,etc-,)
f[. ft. in.
3.Well Use(check well use): 17.`SCREEN` . ''`, J'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.5 ft' 24.5 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 ,_,-.,,:wzs„ _. ';�, .-•. z ,-'
FROM TO MATERIAL -. EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
3 rt. 6 ft. Bentonite:Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVELPACK,'if.ii licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
6 rt• 24.5 rt• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING;LOG ettich i ddifioital 8tieets if iiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/ruck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-26-22 Well ID#AB-5
ft. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21•REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field,one tat/long is sufficient)
35.414336 N -80.806276 N, - —
Signature ofCertitied Well C tractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing flux Jbrnt,/her rli/y that the we/l(s) rr construcled in accordance
with 15A NCAC 02C.(//till or 15A NCAC 02C.0200 Well Cunstrrrctiun J7unelurds and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy gJ'this record has heen provided to the si-ell owner.
ll'this is a repair/ill out known well construction tn/brntalion and explain the nature o/the
repair under a21 rewarks section or on the hack gj'dvis Jbrtn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hbr multiple injection or non-water supply wells ON/.V with the same construction,you call
submit one win. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mu/lip/e we/Lc list a//depths iJ'di/jerenl(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: Unknown (ft.) Division of Water Resources;Information Processing Unit,
/(,rarer level is above casing,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
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.) d
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent Ir,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 ofcompletionof
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