GW1-2022-04505_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: I
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 6eable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING ebthermal dosed-loop)
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: 0 ft. 13 rr. 4 i" SCh40 PVC
List all applicable hell permits(i.e.County,Slate, Variance,Injection,etc.)
ft. I ft. ! in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft- 43 ft- 2 in.i .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. R. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 9 ft- Portland Cem Tremie
Non-Water Supply Well:
[DMonitorine ❑Recovery
9 ft. 11 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL>PACK if a Iicable
,.v
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO
11 ft 43 ft. MATERIAL EMPLACEMENT METHOD
#1!Sand Tremie
❑Aquifer Test ❑SLormwater Drainage rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRR.LING LOG attath�addid'otial stieets if iiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,il rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft. i
ft. ft.
4.Date Well(s)Completed: 2-1 6-22 Well IDN BA-4
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY
14511 Huntersville-Concord Road, Huntersville, NC 28078 rt. e. _
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)
35.414311 N -80.806008 W [ L-3-D oZ
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Ilv signing this.Joan, 1 herehv ceriift that the i e/1(s)was 6 ere)consirucied in accordance
with 15A NC'AC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy oJ7his record has been provided to the well owner.
It'this is a repair,Jill out known well construction inlormaiion and explain the nature q/'the
repair under.21 rentarks section or on the back q/this)i,rni. 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 uyeclion or non-water supply wells ONLY with the same construction,you can
submitoneforni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 43 (ft.) 24a. For All Wells: Submit this loan within 30 days of completion of well
!or nm/tiple wells list all depilis i/'dtfterenl(example-3 ct N/0'and 2@100') construction t0 the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
1/'troter level is above casing,use" 1617 Mail Service Ce M ter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
HSA 24a above, also submit a copy of tHis form within 30 days of completion of well
12.Well construction method: construction to the following: I4I4
(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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this formlwithin 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 201?