GW1-2022-03325_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD Foi Internal Use ONLY:
This fbrm 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 ft. ft. f
NC Well Contractor Certification Number is.OUTER CASING (for multi-cased wells OR LINER if a licable
FROM TO DIAMETERI 'THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 R. ft. 4 in' sCh40 PVC
List all applicable well perntilc(i.e.Counlp,Stale,Variance,Injection,elc.J `,
ft. ft. fin.
3.Well Use(check well use): 17.SCREEN
Water Supply'%Vell: FROM TO DIAMETER ISLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 rr' 32 fr' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I I'D MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑lrri aeon 0 ft' 3 ft. Portland Cem Tremie
Non-Water Supply Well:
0 Mon itoring ❑Recovery
3 ft. 5 ft. Bentonite Chii Tremie
Injection Nell: ft. H.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a'licable
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO MATERIAL 1 EMPLACEMENTMETHOD
5 fr 32 fr #1 Sand Tremie
❑Aquifer Test ❑S[ormwater Drainage fr. fr.
❑Experimental Technology ❑Suhsidence Control 20.DRILLING LOG'attackaddiHonal s heets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Iculin,hardness,suilhock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 1-27-22 Well ID#AF-5
rr. rr.
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 '`^
a. ft.
Physical Address,City,and Zip
21.REMARKS MAP
Mecklenburg
County Parcel Identification No.(PIN) r.... . ,
•3,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one lat/long is sufficient)
35.414624 N -80.806511
Signature of Certified Wel untractur Dale
6.Is(are)the well(s): ©Permanent or ❑Temporary
Hv.cixninK iris,%own, c•erlth,that ill ire//(s)i l (uere)constructed in accordance
nrt iA N(A( l2( .010(or lSA NCA( (2 . . es
Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or ONo capV of this record has been provided to the a e//ouvrer.
l/this is a repair,fill ottl known ire//construction information and explain the nature a%the
repair under=2/rewnrks.ceclinn or on the hock n/7his Jbrnl. 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.
hbr nnthiple injection or non-irtner snpphv wells ONLY with the same construction,you call
.cubmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor m lliple wells/tsl all depths if di//erenl(example-3 n,200'and 2 rt 100.) construction to the following:
10.Static water level below top of casing: Unknown (ft.) Division of Water Resources,Information Processing Unit,
I/grater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the tialn 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(gpm) Method of test:
24c.For Water Supply&Injection Wills:Also submit one copy of this form within 30 days ofcompletionof'
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I Nordt Carolina Department of Environnnent and Natural Resources-Division of Water Resources Revised August 2013