GW1-2022-03262_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:
Anthony Convery 14.WATER ZONES
FROM TO DESCRIPTION:-
Well Contractor Name ft. ft.
4343
NC Well Contractor Certification Number
15.:OUTER-CASING fo'r.indlti-cased wells OR L1NER ff a licable
FROM TO DIAMETER I ! THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16;INNEWCASING ORS TUBING 4icottrerMal closed-loo
FROM TO DIAMETER, THICKNESS I MATERIAL
2.Well Construction Permit#: 0 fr. fr. 4 in. SCh40 PVC
List all applicable well permits(i.e.Counl,,Stale,Variance,Injection,etc-.)
fr. ft. in.
3.Well Ilse(check well use): 17.SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 try 22 ft- 2 i" .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18aGR0UT ,,
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 3 fl- Portland Cem Tremie
Non-Water Supply Well:
RlMonitoring ❑Recovery 3 rt. 5 ft- Bentonite Chil Tremie
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.;SAND/GRAVEL'PACKi ifs`licablef
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENI'METHOD
5 rt 22 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING',L0G!ettiich addthonel"sheets'if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,suith—ktype, pain size,ate.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
rt. rt.
4.Date Well 1-31-22 s)Completed: Well ID#AB-4
ft. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable)
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 lat/long is sufficient)
35.414492 N -80.806155 N,
Signature of Certified We -omracto, Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing This jnrni, erehv certiJv that the we rus(+sere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standarch and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy o/'this record has been provided to the well owner.
//this is a repair,lfll our known well construction inlorniation and explain the nature ol'ihe
repair under,.,21 remarks.section or on the hack of this Jnriu. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l•or multiple injection or non-water supply wells ONLY widr the same construction,_you can
rabina one)arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 22 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far mniliple wells list all depths tl'dtljerenl(example-3@200'mtd 2@100') construction to the following:
10.Static water level below top of casing: Unknown (ft) Division of Water Resourcies,Information Processing Unit,
l/stater level is above casing,use 1617 Mail Service Centelr,;Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In i dlition to sending the form to the address in
HSA w/ Geoprobe 24a above, also submit a copy of thisi form within 30 days of completion of well
1 Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,arc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,,Raleigh,NC 27699-1636
m 13a.Yield
(RP ) Wells:
Method of test: 24c.For Water Supply&Injection 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