GW1-2022-04491_Well Construction - GW1_20220509

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 27 ft• 39 f`• ( Wet
2973 ft. I ft.
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells OR LINER ifa applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft.
Compam Name 16,INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft. 4 in. sch40 pvc
l.i.rt all applicable u•e/I pernnec(i.e.County,State, Variance,injection,etc) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft 39 ft' 4 in. .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. 15 ft- Portland Cem Tremie
Non-Water Supply Well:
❑Monitoring 0 Recovery
15 f`• 17 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
17 f` 39 f` #1!Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionalsheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUmck type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-2-22 Well ID# RW-1 13
z k r
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. v
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft
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)
35.413223 N -80.806001 W K—A­� "10 I © Z 2_
Signature ofCer hied Well Contractor Date
6.Is(are)the well(s): ©Permanent or []Temporary Hv signing dus,/inrm, I herebv certib,that the wells) was(n'ere)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC102C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under.21 remarks section or on the back gflhisJorm. 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.
hor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one/hrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
!br multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
iflrater level is above casing,use' - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: in addition to sending the form to the address in
6 5/8 HSA & 2�� 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,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 within 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 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013