GW1-2022-04501_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:
Anthony Convery 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4343 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased fw6Hs OR LINER ifa fitable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. In.
Compam Name 16.INNER CASING OR TUBING geothermal dosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 ft, 4 in. sch40 PVC
List all applicable well permii.s(i.e.Couniv,State,f%arianc•e,Injection,etc.'
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS \1ATERIAL
❑Agricultural ❑Municipal/Public 9 ft' 34 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f[. ft. io•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 30 ft. Portland Cem Tremie
Non-Water Supply Well:
M Mon itori ng ❑Recoven
30 ft. 32 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
_
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑salinity Barrier 32 ft 34 ft. #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft ft. .
❑Experimental Technology ❑Subsidence Control
20.DRILLING;LOG(attach additional sheetsif necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/mck type,grain size,etc.'
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 3-2-22 Well ID#AA-7
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 0 9 _
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft e
Physical Address,City,and Zip -
21.13E6fARKS ,i v
Mecklenburg
I
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one lat/long is sufficient)
35.414188 N -80.806497 W.
Signature of Certified We Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary Rv signing this firm,/herehv c•ernft that the well(.,) was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConstrucHom Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0 No copy of this record has been provided to the well owner.
!/'this is a repair,fill out known well construction iglbrmanon and explain the nature ofthe
repair under=21 remarks section or on the back at 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.
For multiple injection or non-water supply wells ONLY with the same construction,van can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 34 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it diJJerent(example-3 a 200'and 2@100') construction to the following:
j
10.Static water level below top of casing: Unknown (ft) Division of Water Resources,Information Processing Unit,
/'water lerel 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 fonn wthin 30 days of completion of well
12.Well construction method: HSA w/ Geoprobe construction to the tollowing:
(i.e.queer;ro[arv,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceitei•,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells:
Also submit one copy of this form !thin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county heal)h department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Res o urces Revised August 2013