GW1-2022-09108_Well Construction - GW1_20220926

i
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 23 rr. 39 ft• k' Wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for
O mli-cMedwlls ORLIICNKERS a
ROM DaETER THN liM RIAL
Parratt-Wolff, Inc. ft
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It. jig It. 4 in sch40 pvc
Lien all applicable well perms(i.e.Co nly,Stale,Variance,Injection,etc-.)
e. a. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 19 ft' 39 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heat ing/Cool i ng Supply) ❑Residential Water Supply(sin le) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 15 ft- Portland Cem Tremie
Non-Water Supply Well:
I�Monitoring ❑Recovery
15 ft 17 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if.a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 17 ft' 39 ft #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach i dditiomil sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION cuter,hardness,soil/ruck type,gntin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rt. ft.
7-20-22 MW-100 ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft.
SrP :b
Facility/Owner Name Facility ID#(ifapplicable) ft ft
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 4"Pro Cover
County Parcel Identification No.(PIN) 2 x2 pad
W Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one lat/long is sufficient)
35.412586 N -80.806785 N, 2, 16 ' C"
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hv signing dos form,I herehv certify that the nel/(s)was(were)canslrtrcted in accordance
with 15A NCAC Il2C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
Il'this is a repair,fill out known well construction information and explain the nature oflhe
repair under=21 rentarks section or on the hack mfihis firrni. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor multiple h jection or non-water supply wells ONLY irate the same construction,yam can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this'.form within 30 days of completion of well
/•or multiple wells list all depths t(dtfferent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 23 Division of Water Resources,Information Processing Unit,
Iflraier level is above casing,rise - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: iln addition to sending the nitro to the address in
4 1/4 HSA & 2" spoons24aabove, also submit a copy of this torm 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:
(hP ) Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Enviromwent and Natural Resources—Division of Water Resources Revised August 2013