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GW1-2022-03269_Well Construction - GW1_20220314
i WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used f'or single or multiple wells I.Well Contractor Information: t 14.WATER.ZONES s Anthony Convery FROM TO DFSCRIPTION Well Contractor Name ft. ft. 4343 ft. ft. NC Well Contractor Certification Number 15.-OUTER CASING(for tniulti-cased wells'INER if a p licable FROM TO DIAMETER ` THICKNESS MATERIAL Parratt-Wolff, Inc. rt. ft. I Iin: Company Name 16ANNER CASING OR'TUBING:'eoiherma1.closed4oi FROM TO DIAMETER 1 THICKNESS MATERIAL 2.Well Construction Permit#: 0 fr. $ er. q I lu' SCh40 PVC Lest all applicable Drell permits(i.e.Colntil',stale,Variance,injection,etc'.) rt. ft. in. 3.Well Ilse(check well use): 17.SCREEN. ]; Wafer Supply Well: FROM TO DIAMETER SLOTSIZE I 'THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public 8 rt. 18 1t. 2 i" .010 SCh40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT [ E TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑Irri ation 4 ft- Portland Cem Tremie Non-Water Supply Well: 0 Monitoring ❑Recovery 6 ft Bentonite Chi Tremie Injection Well: ft. ❑Aquifer Recharge ❑Groundwater Remediation RAVEL,PACK,'ifti"licable TO MATERIAL! EMPLACEMENT METHODy ❑Aquifer Storage and Recovery ❑Salinity Barrier 18 rt. #1 Sand Tremie ❑Aquifer Test ❑Stormwater Drainage❑Experimental Technology ❑Subsidence ControlNG LOG attach eildthoiiel'sheef's-if necessa ❑Geothermal(Closed Loop) ❑'tracer FROM TO DESCRIPTION calar,hardness,suilh'uck t e,graii,si-,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft. ft. ft. 4.Date Well(s)Completed: 2-1-22 Well ID#AA-4 ft. ft. 5a.Well Location: ft. rt. 1.=^! '' :t '�S f" Colonial Pipeline Company Facility/Owner Namc Facility IM(ifapplicable) ft. ft. 14511 Huntersville-Concord Road, Huntersville, NC 28078 Physical Address,City,and Zip . . 21.;REI1fARKS " - Mecklenburg County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: (ifwell field,one lat/long is sufficient) 35.414396 N -80.806049 W U\ Cni, Signature of'Certitied Well mractor Date 6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this/ornl, l here y cerit&that)lie well(s)it as(irere)constructed in accordance with 15A NCAC 02C.I1100 or 15A NCAC 02('.0200 Well('onstructiott sluiidurcic and that a 7.Is this a repair to an existing well: ❑Yes or ONo cow ry'this record has been provided to the well owner. l/this is a repair..fill our known irell c•onsaruclion infortnalion and explain the nalure of the repair under=21 remarks.section or on the back q(Ihi.c/orm. 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. l•or nnilliple injection or non-waler supply wells ON/.Y with the same cons[ruetion,you Can submit one form. SUBMITTAL INSTUCTIONS I 9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well Hor ntulliple wells list all clepihs iI ilillerenl(example-3 a 200'and 2@11iff) construction to the following: i Unknown Division of Water ResourcIes,Information Processing Unit, l0.Static water level below top of casing: (ft.) g //)rater level is above casing,ore' 1617 Mail Service Cent er,'IRaleigh,NC 27699-1617 11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In I ddition 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 Center,`Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test: 24c.For Water Supply&likiection Wells: 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 Not Carolina Department of Environment and Natural Resources—Division of'Water Resources Revised August 2013