GW1-2022-04509_Well Construction - GW1_20220509

i
WELL CONSTRUCTION RECORD
For Internal 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 ft. ft.
2973 ft. ft. j
NC Well Contractor Certification Number 15,OUTER CASING formolti-cased wells OR LINER ifa Hcable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING et thermal dosed400
FROM TO DIAMETER THICkNESS MATERIAL
2.Well Construction Permit#: 0 7 fr. 4 in. SCh40 PVC
List all applicable well permits(i.e.County,State.I'ariance,hileclion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 ft' 32 ft. 2 in. I 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Portland Cem Tremie
Non-Water Supply Well:
3 fr. 5 fr. Bentonite Chil Tremie
OMonitorine ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK i112 liClAbIC
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. 32 fr.
#1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage 5
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach:additional sheets if,necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
rL ft.
Date Well 1-25-22 s)Completed: Well ID# BA-7
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
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 lat/lona is sufficient)
35.414188 N -80.806270 W. (4"
Signature ofCertitied Well Contractor I Date
6.Is(are)the well(s): IZPermanent or ❑Temporary yv signing this farm,1 herebv ceruli,that the wells)was 6rere)constructed in accordance
wilh I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy q/'dus record has been provided to the well owner.
lfdfi.s is a repair,fill out known well construclion information and explain the nature ofthe
repair under-21 remarks section or on the back oJ'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.
h'or nwhiple injection or non-irater.supply wells ONLY with the same construction,You can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple uve//.s list all depths ifdt#J rent(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: Dry Division of Water Reso irces,Information Processing Unit,
:/barer lerel is above casing,use"-" 1617 Mail Service Center,ter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
HSA 24aabove, also submit a copy of this form wthin 30 days of completion of well
12.Well construction method construction to the following: i
(i.e.auger,rotarv,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
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county heath',department of the county where
iconstructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i