GW1-2022-04504_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal use 0NLv:
This form can be used for single or multiple wells j
I.Well Contractor Information:
!i I
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-lino
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 19.5 ft. 4 in. sch40 PVC
List all applicable well permits(i.e.Uounttt State,Variance,Injection,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 19.5 ft' 39.5 ft' 2 in. 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in•'
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 rt• 17 ft- Portland Cem Tremie
Non-Water Supply Well:
2Monitorina ❑Recover'
17 fr 17 rr• Bentonite Chil Tremie
Injection Well: fr. fr.
i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAV'EL PAC K if a'licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 17 rr• 39.5 ft- #1Sand Tremie
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control 20..DRILLING LOG attacb,addihon$Csheets'.if necissa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under 421 Remarks)
ft. ft.
4.Date Well(s)Completed: 2-8-22 Well ID# BA-3 R. ft.
5a.Well Location:
Colonial Pipeline Company ft. fr. ^'
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. MAY 0 9 �02?
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip
21:REMARKS ;. { Lt�lrw•.:_�Jt)1S:ff7
Mecklenburg -J1 ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/lone is sufficient)
35.414375 N -80.805975 W a w a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 herebv cerh/i`that the it ell(s)was(were)constructed in accordance
with USA NCAC 02C.0100 or 15A NC'AC:02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑V es or ElNo copy ojthis record has been provided io die well owner.
h"this is a repair,Jill out known n•el/c•on.sirucaion in/brntation and explain the nature q/7he
repair under-21 reniarkv section or on the back of 1his jinn. 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.
Por multiple injection or non-water supply wells ONLY with tine same construction,voa can
submit oneJhrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39•5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths t/'dtJ(erent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: Dry Division of Water Resources,Information Processing Unit,
I/water level is abore casing,use ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In addition to sendine the form to the address in
24a above, also submit a copy of this form Hithin 30 days of completion of well
12.Well construction method: HSA construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,LI)nderground 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
13b.Disinfection type: Amount: well construction to the county health'department of the county where
constructed. i
Form GW-I North Carolina Department ot'Environnnent and Natural Resources-Division oC Water Resources Revised August 2013