GW1-2022-03663_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used fix single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM I'D DESCRIPTION
Well Contractor Name 42 ft• 53 ft' f Wet
2973
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
FROM TO DIAMETER: THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 113 ft. 4 in• sch40 pvc
List all applicable nell pennits(i.e.County Seale,Variance,Injection,etc-.)
ft. ft. 'in•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 f" 53 ft. 4 in. .010 sch40 pvc
f. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 rt. 9 rt. Portland Clem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 9 R• 11 ft Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11 ft• 53 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/tuck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) R. ft.
ft. ft.
4.Date Well(s)Completed: 1—25-22 Well ID# RW-109
ft. ft.
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicahle)
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 lat/long is sufficient)
35.414833 N -80.806780 N, ,�
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv.signing Ihi,s/nun, 1 herebv c•ertih,than)he wee/(s)was(n/1 6 a i ,ggqg3f$, t,
wall 15A NCAC QU.0100 or 15A NCAC 02C.0200 Well('tlltaNklim Is;, rtYs'ir tbihu cp
7.Is this a repair to an existing well: ❑Yes or 171 No copy q/this record has been provided to tile well owner.
//'this is a repair,Jill out known well construction in/nrmation and explain the nature a/'die MAR 2..1
repair under s21 remarks section or on lite back o/'this.1brm. 23.Site diagram or additional well details:You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if fiePessary.,,
har multiple injection or non-water supply wells ONLY with the saute construction,rou call IN"�r:•.e,--ii��,t �Cr'�...��C:.:.•';i^_IJ��I
subtuil one iornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 53 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
1•ar nutlliple wells list all depths i/'dijferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 42 (fL) Division of Water Resources,Information Processing Unit,
ry'u•ater level is abore casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: It addition to sending the form to the address in
6 5/8 HSA & 2t� spoons24aabove, 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,Linderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
tgP ) Also submit one copy of this form pwithin 30 days ofcompletionof
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I Not-tit Carolina Department of'Environment and Natural Resources—Division of Water Resources Revised August 2013