GW1-2022-04516_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
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1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'weHs OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft- 19 ft. q in- SCh40 pVC
List all applicable well permits(i.e.Couniv.State,Variance,Injection,ere.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 19 ft. 44 ft. 2 to 010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT{
❑Irri ation 0 fL 15 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
15 ft. 17 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK'ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 17 ft. 44 ft. #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG,attach addittonalisheets if uecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/mck e,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-30-22 Well ID# BC-7
ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company fr. 13. t-w. � ,�._: `°,.�r ._'_I^.-'a
Facility/Owner Name Facility ID#(ifapplicable) ft. f[. MAY 0 A 7
14511 Huntersville-Concord Road, Huntersville, NC 28078 fr. a. i7
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:
` /
(3well field.one[at/long is sufficient)
35.413680 N -80.805957 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form, I herebv ceriifv that)the wel/(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC b2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oj'this record has been provided to the well owner.
If this is a repair,fill out known well construction infornmtion and explain the nature oJ'the
repair under 21 remarks section or on the back gfthiy.1brm. 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 well.v ONLY with the same construction,you can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 44 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list a//depths#Vd 11&rent(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,
Ijb•ater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b. For Injection 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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,L)nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cenitei",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
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201?
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