GW1-2022-03326_Well Construction - GW1_20220314

II
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fin in can be used for single or multiple wells
L Well Contractor Information:
r
Anthony Convery 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4343
NC Well C'ontiactm Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ti licable
FROM TO DIAMETER THICKNESS MA"1'ERIAL
Parratt-Wolff, Inc. ft. ft. I
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER ,j THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 R. 4 in. sch40 PVC
Osi all applicable irell permits(i.e.Cennitp,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 19.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE "THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 D' 34 r`' 2 in. I .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 4 ft- Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recover' 4 r`' 7 fr Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
7 r` 34 f' #1 Sand Tremie
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addiHonal!sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hmdness,suithock l in,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑ether(explain under 421 Remarks) ft. ft.
4.Date Well 1-27-22 AF-3 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. I' '` i.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
fr. ft. t" . .,
Physical Address,City,and Zip 1
21.REMARKS ,
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field,one lat/long is sufficientl
35.414764 N, -80.806238 N, a—
Signature ofCer hied Well Co 'actor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form, I here. ,i/y that the ueN(,)iruc(here)constructed in accordance
irirh 15A NCAC 02C.0100 or 15A NCAC Illy.0200 Well('unstructiun JYundurds and that a
7.Is this a repair to an existing well: ❑Yes Ur ONo copy gjrhis record has been provided to the 4re!!owner.
!(this is a repair,fill out knouvn well construction hi irmation and explain the nature o/?he
repair under,21 remarks section or on the hack q/'thi.c jorn,. 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 ntulliple ityec•lian or non-irnier.supp/v irells ONI.Y irirh the sunie cottrrruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 34 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hhr nw/tip/e ire//s/i.rr all depths if di/jerew(example-3 u,200'and 2@ 100') construction to the following:ft
10.Static water level below top of casing: Unknown ( ) Division of Water Resources,Information Processing Unit,
lfirater level is abore casing,u.se 1617 Mail Service Center,Raleigh,NC.27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: Inladdition to sending the form 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 or Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,''Raleigh,NC 27699-1636
k
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection Wells:Also submit one copy of this form w�ithin 30 days ofcompletionof'
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 1013