GW1-2022-03269_Well Construction - GW1_20220314

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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
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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:
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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