GW1-2022-03662_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single m multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 f[. 32 ft. Net
2973
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weUS OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 7 ft. 4 in SCh40 I pvc
List all applicable melt permits(i.e.Coun/v,Slate,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 ft. 27 ft. 4 in. .010 1sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 R' 3 ft- Portland!Cem Tremie
Non-Water Supply Well:
12l Mon itori ng ❑Recovery
3 ft. 5 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.'SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FNIPLACEMENTMETHOD
5 fr. 27 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ,
20.DRILLING LOG(attach additional{sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sou/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. fr.
4.Date Well 1-19-22 s)Completed: Well ID# RW-107
ft. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg No Cover
County Parcel Identification No.(PIN) '..
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field,one[at/long is sufficient)
35.414522 N -80.806307 W a .1AD'
Signature ofCertilied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv.signing this/brit,I hereby cerlij,that the ue//(s ere constructed in accordance
with lSA N('A('I12C.0/I)0 or lSA N('A['02C.0200 l ' t Ir ct7h an d that a
r ,.d.
7.Is this a repair to an existing well: ❑Yes or [7]No copy q/7hic record has been provided to the well corn r.
If this is a repair/ill out known well construction iglormation and explain the nature of the
repair under�2I remarks.section or on the back n/'this jornh. 23.Site diagram or additional well details: MAR .a. f'lt�You may use the back of this page to provide additional si a gils of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
P'nr milli !e injection or inn-water su !N wells ONLY hrilh the.came construction,ynu can r' •�.r�I�si�,
submitone/orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 27 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or muhiple+reRs list all depths i(di//ereni(example-3 a 200'mud 2 r(✓1 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
If water level is above caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA & 2tt Sp00nS 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,l.Inderground 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 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. I
Form GW-I North Carolina Department of'Environnient and Natural Resources-Division of Water Res urces Revised August 2013