GW1-2022-03265_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 for multi-cased welld ORjLINER-if.a" 'licable_ .
FROM TO DIAMETER THICKNESS MA'I'EHIAI.
Parratt-Wolff, Inc. ft. ft. in;.
Company Name 16.INNER CASING OR'-TUBING `eoihermil citised-lootill
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 6 fr. q in. SCh40 pvc
List all applicable trell perntil.v(i.e.Countyy,State,Variance,/njeetion,etc-,)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN. ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6 ft. 36 ft. 2 in.
.010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO `MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑irri ation 0 fr. 2 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
2 ft. q ft- Bentonite Chii Tremie
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 iSAND/GRAVEtikACK ifi6 licabte .
FROM TO MATERIAL EMPLACEMFN'I'METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 rt. 36 a. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Suhsidence Control
20:DRILLING3L G(itteih'idditi6nal 9heefi1fnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock type,gnain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 2-1-22 Well ID#AB-2
ft. ft.
52.Well Location:
Colonial Pipeline Company ft. rr.
Facility/Owner Name Facility ID#(ifapplicable) fr. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
2t:RE61ARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one bat/long is sufficient)
35.414560 N -80.806133 W i(4.3 Signature ol'Cenified Well tractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
HV signing this Jbnt r , l v _ cerli/y that the wells rereJ constructed in accordance
+rilh 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that it
7.Is this a repair to an existing well: ❑Yes or ONo copy ol'this record has been provided to the well ouvter.
q this is a repair,fill out knotrn reel/construction in/ilrmation and explain the nature oJ'the
repair under i:21 rentarks section or on the hack gf1hi.v farm. 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.
b'or nuulliple injection or non-water supply welly ON1.Y whit the sante construction,You can
submit one%brit(. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 (ftJ 24a. For All Wells: Submit this foim within 30 days of completion of well
1,16r mudliple tee//v fist a/l depths tI th Jerenl(example-3 a,200'and 2@100') construction to the following:
i
10.Static water level below top of casing: Unknown Ift) Division of Water Resources,Information Processing Unit,
//'water level is ahm•e casing,use"•" 1617 Mail Service Cent er,'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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent r,Aaleigh,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 ofcompletionof
13b.Disinfection type: Amount: well construction to the county healthy department of the county where
constructed.
Form GW-I North Carolina Department of'Enviromuem and Natural Resources-Division of Water Resources Revised August 2013