GW1-2022-03267_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple Hells
1.Well Contractor Information:
Anthony ConVG'ly 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
4343
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wehs OR LINER if a disable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. in.
Company Name 16.INNER CASING'OR.UBING eothermal closed-loop)
FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 ft. 4 in. sch40 PVC
/.ist all applicable well permits(i.e.('aunty,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public g ft' 24 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT MF FHOD&AMOUNT
❑Irri ation 0
Non-Water Supply Well: ft. 4 e. Portland Cem Tremie
OMonitoring ❑Recovery
4 ft. 7 ft. Bentonite Chil Tremie
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.if Applicable)
❑Aquifer Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL EMPLACEMENTMETHOD
ft• ft•
❑Aquifer Test ❑Slormwater Drainage 7 24 #1 Sand Tremie
tr. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach idditional�sheets if necessa`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,su0/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well(s)Completed: 2-3-22 Well ID#AA-5
ft. tr.
tr. ft.
5a.Well Location: ft. rt.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
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:
(it\well field,one lat/long is sufficient)
35.414300 N -80.806146
Signature ofCenified I Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
0v signing This Jhrm, by cerii/j,that the well s w mere)constructed in accurzlance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We//Construclion StandurtA and that a
7.Is this a repair to an existing well: 01'es or ❑No copy at record has peen pro•ided to the well owner.
4'thi.s is a repair,fill out known well construction iglorntalion and explain the nature o/the
repair under z21 remarks section or on the hack a/'this/hrm. 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.
For multiple injection or non-water supply we/A ONI.Y with the same construction.You can
submit one form. SUBMITTAL INSTUCTIONS
I
9.Total well depth below land surface: 24 24a. For All Wells: Submit this toIrm within 30 days of completion of well
hor multiple wells list all depths if thf/ereni(example-3 ct,200'and 2@100') construction to the following:
Unknown Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.) , g
/fnater level is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: Inaddition to sending the turm to the address in
HSA w/ Geoprobe 24aabove, 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 Center,Raleigh,NC 27699-1636
13a.Yield Method of test: 24c.For Water Supply&Injection Wells:
(gPm) Also submit one copy of this form within 30 days atcompletionof
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