GW1-2022-04517_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. I
2973 fit. fit. I.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedER I TH wens OR LINER if a 'licable _
FROM TO DIAMETICKNESS MATERIAL
Parratt-Wolff, Inc. fit. ft. I ! ir.
Compam Name `16.INNER CASING OR TUBING` s:&hermal dmtd-loo
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fit. 111.5 ft' 4 1n. sch40 PVC
List all applicable hell permits(i.e.County.State,Variance,Injection,etc.)
ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER + SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11.5 ft' 36.5 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) IS•GROUT ;.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. fl-
O g Portland Cem Tremie
Non-Water Supply Well:
@Monitoring ❑Recovery 8 ft. 9.5 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVELPACK ifa `licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fit
❑Aquifer Test ❑Stormwater Drainage 9.5 ft• 36.5 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
,20.DRELLING,LOG &fi ctisadditionaF sheeisaif,necessa -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 2-2-22 Well ID# 1313-6
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
ft. ft. "h�
Physical Address,City,and Zip
,21 REMARKS', 1z 7
Mecklenburg
County Parcel Identification No.(PIN) ;{T'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: C :vt ii Imo'+'j 1'i"• )..t. i,vm;)i )i
22.Certification:
(ifwell field.one[at/long is sufficient)
35.414020 N -80.806037 W. 1J
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this.form, 1 herebv certify that the srell(s)Bras(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 101C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KJNo copy ofthis record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back gfihis form. 23.Site diagram or additional well details:
You may use the back of[his page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessarv.
For multiple injection or non-waler supply wells ON/_Y with the same construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ drflereni(example-3@200'and 1@a 100') construction to the following:
10.Static water level below top of casing: Dry Division of Water Resources,Information Processing Unit,
1j water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 246. For Iniection Wells ONLY: In addition to sending the form to the address in
HSA 24aabove, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the tollowmg:
(i.e.auger,rotary,cable,direct push,etc.) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce ter,Raleigh,NC 27699-1636
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 health-department of the county where
constructed.
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Form GW-I Noah Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013