GW1-2022-09107_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used f'or single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 37 ft• 55 ft' I Wet
2973 ft. I ft.
I
NC Well Contractor Certification Number 15.OUTER CASING for multt-cased wells OR LINER if a licable
FROM TO D,METER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. Ift. I in.
Company Name 16.INNER CASING OR TUBING eotherrnal closed-loop)
FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 30 ft- 4 "' 1 sch40 I pvc
List`all applicable well perndts(i.e.Candy,Stale,Variance,Injection,etc..)
ft. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE "THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft' 55 ft. 2 1n. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑lrri ation 0 ft. 26 ft- Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recovery
26 fr• 28 fr• Bentonite Chil Tremie
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
28 fr• 55 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG att5eh additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rucktype,gimin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well 7-23-22 MW-101 r.
s)Completed: Well ID# ft, fr.
Sa.Well Location: ft. R.
SEP
Colonial Pipeline Company
Facility/Owner Name Facility ID#(ifapplicable) -G?
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
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient) /\ 11' —
35.412863 N -80.805396 N, h�V' `�✓
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this firm,1 herehv certify that the well(s)was(mere)constructed in accorclanc•e
with 15A N'AC 02C.0100 or 15A NCAC 02C.02011 Well('un.rtructiun Jtundardv and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cow q/this record has been prorided to the well owner.
/f'lhis•is a repair,Jill oul known well construction hilbrtnation and explain the nature gfthe
repair under=21 remarks section or an the hack gf.lhi.v Corm. 23.Site diagram or additional well details:
You may use the back of this page Ito provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hbr nn iliple injection or non-water st&v wells ONLY with the same construction,You can
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 55 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nwhiple wells list al/depth.v t/'di/jerenl(example-3 a,200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 37 (ft•) Division of Water Resources,Information Processing Unit,
1(rrater level is abore caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: iln addition to sending the form to the address in
4 1/4 HSA 24aabove, also submit a copy of this form 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&Injectionl Wells:
(gP ) Also submit one copy of this torn within 30 days ofcompletion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I No th Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013