GW1-2022-09106_Well Construction - GW1_20220926

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This torn[can be used for single or multiple wells `
L Well Contractor Information:
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 licable
FROM TO DIAMETER THICKNESS MA'fFRtAL
Parratt-Wolff, Inc. fr. ft. in.
Company Name 16.INNER CASING OR TUBING etithermal closed-loocil
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit k: 0 ft' 18 ft- 4 in. SCh40 PVC
Lill till applicable+cell permits(i.e.Coiauy.,State,Variance,lnjection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 ft. 28 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. fr. in,
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 fr. ft.
14 Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovery
14 fr 16 fr Bentonite Chil Tremie
Injection Well: ft. fr.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if.applicable)
M
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ATERIAL PLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 16 ft- 28 ft• #1 Sand EM Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 8-3-22 MW-102s)Completed: Well ID#
5a.Well Location: r Ck 2Lf1,z�
Colonial Pipeline Company ft. ft.
)n�•a;;,
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. r t•,,+'^^^^��.:;�'� " '
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 8°Flush Cover
County Parcel Identification No.(PIN) 2 x2 pad
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient)
35.412102 N -80.805305 W
Signature of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary
Hv signing this jhrnt,!hereby c•ertiji,drat the me//(s)uus'(mere)constructed in accordance
with I5A NCAC 02C.(100 or 15A NCAC 02C.0200 Well Construction Steoulurds and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been prorided to the+rel/ouvter.
/(this is a repair,fill out known well construction in/iwrrtation and explain the nature a/7he
repair under=2/rentarks.section or on the hack o/'this jornt. 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.
14rr nwhiple injection or non-mater.smpph,wells ON/.Y with the same construction.you con
.submit one/brit. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 24a. For All Wells: Submit this form within 30 days of completion of well
/•or multiple wells list al/depths if di/Jerent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
l/'water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 246. For Injection Wells ONLY: ;ln addition to sending the foam to the address in
4 1/4 HSA & 2" SpOOnS 24aabove, also submit a copy of this torn within 30 days of completion of well
12.Well construction method: construction to the following:
(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 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013