GW1-2022-04495_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Interval 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 43 ft 66 ff Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mtdt se i-cad wells OR LINER
FROM TO DIAMETER THICKNESSa licable MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING geothermal closedaoo '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 36 ft. 4 i" SCh40 PVC
List all applicable well pernttis(i.e.Countyy,Slate, I,ariance,Injection,ete.J ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 36 ft. 66 ft' 4 in.
.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ]S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f" 32 ft. Portland Cem Tremie
Non-Water Supply Well:
❑Monitoring EIRecovery
32 ft 34 ft. Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
EMP
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL LACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 34 ft- 66 ft. #1 S Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheetsif necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION lcolor.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 3-4-22 Well ID# RW-116
ft. ft. r� F'- .
Sa.Well Location: ft. ft.
Colonial Pipeline Company e. ft.
Facility/Owner Name Facility lD#(if applicable) M AY o
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft. - 1
Physical Address,City,and Zip We
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)
35.413344 N -80.805524 W /Y.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this,Jiirm, 1 hereby ceriifV that the❑�ell(s) eras(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C'onsiruciion Siondards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy q(dits record has been provided to the we//owner.
If this is a repair,Jill oat known well construction inilbrmaiion and explain the nature of the
repair under=21 reniarkv section or on the back of'Jus fbrm. 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.
Fior midt/ple injection or non-water supply we/A ONLY with the same construction,you can
submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 66 (ft.) 24a. For All Wells: Submit this torm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 ci 100') construction t0 the following:
10.Static water level below top of casing: 43 (ft.) Division of Water Resources,Information Processing Unit,
y'water level is above caving,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 within 30 days of completion of well
6 5/8 HSA & 2�� SpOspoons12.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
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this formiwithin 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013