GW1-2022-09110_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. +t,
2973
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO D1.4METER 'THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING etthermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 R• 20 fr• 2 i" sch40 pvc
Lis/all applicable irell pernni.s(i.e.Connty,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 30 R• 2 i" .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rt. 16 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 16 ft 18 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
18 ft 30 f� #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hardness,soiltrucktype,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 7-26-22 MW-10Rs)Completed: Well ID#
5a.Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID4(if applicable) _
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078t :,
Physical Address,City,and Zip (,, ,.
21.REMARKS -
Mecklenburg 2 x 2 Pad
County Parcel Identification No.(PIN)
4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.414081 N -80.807760 W
Signature ofCettitied Well Contracloi - Date
6.Is(are)the well(s): ©Permanent or ❑Temporary g / J} ) (
Hv.+'i nin�dtis Dint,/berets ecru dui/thee hell(s uwashere)constructed in accordance
irith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consvruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been prortded to the i e//owner.
//'this is a repair,Jill out known well c•nn.siruc•tion in/arwaiion and explain the nature oldie
repair under r:21 remarks section or on the hack of this/hrw. 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.
har nwhiple hyeelion or non-irater supply wells ONLY irate the.same construction,you can
suhn it oneJorni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 24a. For All Wells: Submit this form within 30 days of completion of well
I•ar nwhiple wells list all depdts iftli(fereni(example-3@200'and 2 rt/00') construction to the following:
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10.Static water level below top of casing: None (ft► Division of Water Resources,Information Processing Unit,
If irater level is abore casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: yin addition to sending the form to the address in
4 1/4 HSA & 2" SpOOnS 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 Celtiter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&lnjectiona Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environntenl and Natural Resources—Division of Water Resources Revised August 2013