GW1-2022-04488_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD
For Internal Use ONLY: C
This form can be used for single or multiple wells
i
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa livable
FROM TO DIAMETER THICIaVFSS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBINGfize6thermall closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 9.5 ft- 4 in. SCh40 PVC
List all applicable well permits(i.e.Couniv,State, Variance,hrjec•rimr,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.5 It- 29.5 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 6 It- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 6 f`' 7.5 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK ifsi `livable
FROM TO MATERIAL EMPLACEMENT"METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 7.5 ft' 29.5 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING_LOGatta"ch'addifionat sheets if riEcasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-4-22 Well ID# BB-7 ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr ft
Physical Address,City,and Zip - -
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
35.413961 N -80.806160 W. K -4-C1-111 2-' 2Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing this*orm, I hereby certifv Thai the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC'01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of'dus record has been provided to tie well owner.
/*this is a repair,Jill out known well construction information and explain the nature q*the
repair under-11 remarks section or on the back q/'this firm. 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 necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one Jorm. SUBMITTAL INSTUCTIONS
29 9.Total well depth below land surface: '5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Pbr muhiple wells list al/depths tJdt(*ereni(example-3@100'and 2 a 100') construction to the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resoul ces,Information Processing Unit,
IJ'svaler level is above casing,use 1617 Mail Service Ce I ter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA 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 Wells:
Also submit one copy of this form Iwithin 30 days ofcompletion of
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 2013