GW1-2022-04494_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
1.Well Contractor Information:
r ,
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 32 ft• 46.5 ft' I Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ficable
FROM TO DIAMETER! THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I
I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 121.5 ft' 4 '" sch40 PVC
List all applicable well permits(i.e.C ountR State, Variance,injection,etc.)
ft. I ft. I in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 21.5 ft' 46.5 ft• 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 f. 17.5 fr' Portland Cem Tremie
von-Water Supply Well:
❑Monitoring RlRecoven 17.5 rt• 19.5 rt• Bentonite Chil Tremie
Injection Well: tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicabit
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.5 ft- 46.5 ft- #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,soit/mck type,pmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well 2-23-22 RW-114 s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID4(ifapplicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg NoCoveF::`�"'
County Paicel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one]at/long is sufficient)
35.413382 N -80.805963 W. As ( Vr /O- ZZ
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing This jbrm,1 herebv ceri/ft that the rrel/(s)uas(were)constructed in accordance
with I5A NC'AC 07C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EI No copy cif this record has been prorided to the well owner.
1/this is a repair,fill out known well construction i ilbrrnalion and explain the nature at the
repair under:21 remarks.section or on the back of this fortnn. 23.Site diagram or additional well'Actails:
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-❑rater supp/v wells ONLY with the same eonstraclion,you can
.submit one jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor nnultiple wells list all depdns it d/(ferent(erannple-3@200'aml2 tt 100') construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
4!rater level is above casing,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
„ 24a above, also submit a copy of this form ,vithin 30 days of completion of well
12.Well construction method: 6 5I8 HSA , & 2 Spoons 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 Ce h ter,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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013