GW1-2022-04512_Well Construction - GW1_20220509

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells !
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased(wells)OR LINER if a Gcable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING 6thermal closed-loon)
FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft- 11 ft 4 i" SCh40 PVC
List all applicable well perntirs(i.e.Uotiniv,Stafe, Variance,Injection,etc.)
ft. I ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 It- 36 f`• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 6 5 ft- Portland Cem Tremie
Non-Water Supply Well:
2 Mon itoring ❑Recovery
6.5 f` 8.5 It- Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK if a'licahle
-
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
8.5 ft- 36 #1lSand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20..DRILLING'LOG:attach:additional-sheits-if tice6sii"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-2-22 Well ID# 1313-5
5a.Well Location: ft. ft.
Colonial Pipeline Company
Facility/Owner Name Facility ID4(ifapplicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
,Physical Address City, { t y ty,and Zip 21.REMARKS
_.�r+.sdt.Cil}l�nn!1 fL:i"tfi
Mecklenburg
County Parcel Identification No.(PIN) t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one IaUlong is sufficient)
35.414306 N -80.806099 W. a a��• a�
Signature of Certified Well Contactor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form, I hereby cerliJy that the well(,) was(sere)consiructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well:. ❑Y-es or ONo copy q/'this record has been provided to the well owner.
U this is a repair/ill oul known well construction information and explain the nature of the
repair under a21 remarks section or on the back q/'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-waler supply wells ON1,Y wish the same construction,yo i can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/!s list ail depths ifdl fjerent(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this'form 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,Linderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceniter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: lac.For Water Supply&Injection Wells:
Also submit one copy of this form jwithin 30 daysofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Enviromuem and Natural Resources-Division of Water Resources Revised Aueust 2013