GW1-2022-04493_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: I
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 32 ft 39 ff Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR L1NER if a fieable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Contpam Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 20 ft. 4 in. SCh40 PVC
List all applicable we//permits/i.e.Couniv,State.Variance,lnjection,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 "' 39 f" 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 tt• 15 ft. Portland Cem Tremie
Non-Water Supply Well:
❑Monitoring EIRecovery
15 ft. 17 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 ft' 39 ft. #1,Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'addiftonal sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-24-22 Well ID# RW-1 15
ft. ft.
5a.Well Location:
ft. ft.
Colonial Pipeline Company ft. ft. _
Facility/Owner Name Facility ID#(ifapplicable)
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:
(ifwell field,one]at/long is sufficient)
35.413263 N -80.806844 W �( � (iCJt !�•�(} Z z
Signature of'Certitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this/orm, 1 hereby cerai',that the trell(s) u•as(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gjthis record has been provided to the well owner.
Ij this is a repair,till out known well construction information and explain the nature gjthe
repair under=21 remarks.section or on the back gjthis/brm. 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.
I•br nmltiple injection or non-eater supply ve/ls ONLY irah the same construction,you can
submit onefbrm. 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
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the ollow'ing:
I
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
,rater level is abore 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.) I
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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Deportment of Environment and Natural Resources-Division of Water Re`sow'ces Revised August 201?