GW1-2022-03266_Well Construction - GW1_20220314

l :
WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This tm ni can be used far single or multiple wells
I.Well Contractor Information:
Anthony Convery 14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4343 ft. e. i
NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS 111 A'fER1AL
Parrott-Wolff, Inc. rt. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loopI
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 rt. 8 5 rr. 4 , in• SCh40 pvC
Lisa all applicable well permils(i.e.Comn(v•Stale, Variance,Injection,etc.)
ft. ft. i in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.5 ft' 33.5 ft- 2 in. 010 SCh40 PVC
f. f. in. i❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
UFROMTO MATERIAL EMPLACEMENI'PIE•fHOU&AMOUNT❑Irri ation 3ft. Portland Cem Tremie
Non-Water Supply Well:OMonitoring ❑Recover' 5 fr Bentonite Chi Tremie
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation RAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENTMETHOU
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft ft
❑Aquifer Test ❑ 5 33.5 #1 Sand TremieStormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control
20.-DRILLING LOG:(attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION calm-,hardness,suit/ruck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 2-3-22 Well ID#AA-6
5a.Well Location:
Colonial Pipeline Companyr `
P
Facility/Owner Name Facility IM(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 rr 1
. rt.
Physical Address,City,and Zip -
21,REMARKS
Mecklenburg -
County Parcel Identification No.(PIN) .,I-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one tat/long is sufficient)
35.414300 N -80.806146 W
Signature of'Cerlifie I ell Contractor Date
6.is(are)the well(s): ZPermanent or ❑Temporary'
l'I signing this./i In c•erviJi,that a)way(u•ere)constructed in accordance
rroh 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that o
7.Is this a repair to an existing well: ❑Yes or ONo copy q/this record has been provided u,i/ne'well toyer.
If this is a repair,fill out known+ref/construction a?1brmalion and explain the nature o/the
repair under=21 remarks.section or an the back ofthir/ornr. 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.
hor multiple injection or non-water supply wells ON1.Y with the same construction,you can
suborn one.loin. SUBMITTAL INSTUCTIONS I
5
9.Total well depth below land surface: 33. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
b'or nudliple wens list all depths i/'dillerenl(example-3@200•and 2 n 100') construction to the following:
i
Unknown Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) g
l/'water Jere/is above caving,use•. 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: Inladdition to sending the tutor to the address in
HSA w/ Geoprobe 24a above, also submit a copy of this form within 30 days of completion of well
12.AYell 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 Centler,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 healtli department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013