GW1-2022-04497_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information: Il
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 if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO I DIAMETER I THICK'NFSS MATERIAL
2.Well Construction Permit#: 0 ft- 41 ft- 2 in. SCh40 PVC
l.i.st all applicable well pernury(i.e.County,Slate,Variance,hycclion,etc•.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 41 ft. 61 ft' 2 t"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT is
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
0 37 Portland Cem Tremie
Non-Water Supply Well:
�Monitoring ❑Recovery
37 ft• 39 ft- Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
39 ft' 61 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach,additionaUsheets'if necessii
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 1/24/22 MW-25R ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. ,
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. Mgt 0
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)
35.414629 N -80.805251 W. ��� �-
Signature of'Certitied Well Contractor Date
6.Is(are)the well(s): UPermanent or ❑Temporary By signing this./brm,I herebv cerur i-that the veN(s)was(here)constructed in accordance
with ISA NCAC 02C.010I1 or ISA NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E1No copy gfthis record has been provided to the well owner.
lf7his is a repair,fill out known well construction information and explain the nature of the
repair under.21 remarks section or an the back of this form. 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 wish the same construction.i au can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 61 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple wells list a//depths ifdiflerem(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: Dry (ft.) Division of Water ReCc rcles,Information Processing Unit,
h"traler level is above casing,use•• 1617 Mail Service nteIr,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of thislfotm 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
136.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