GW1-2022-00121_Well Construction - GW1_20221219

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.
l
2973 ft. ft.
NC Well Contractor Certification Number °15.OUTER CASING formulti-cased wells OR LINER if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 1'6.INNER CASING OR TUBING ebthermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 72 ft. 2 i" sch40 PVC
List all applicable well permits(i.e.County,State;Variance,b jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 72 ft' 77 ft' 2 " .010 1 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 et. 68 ft. Portland Cem Pour
Non-Water Supply Well:
@Monitoring El Recover), 68 ft. 70 ft. Bentonite Chil Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. MATERIAL EMPLACEMENT METHOD
FROM TO ft•
❑Aquifer Test ❑Stormwater Drainage 70 77 #1'Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,saillrock type,grain Size,ere
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Wen(s)completed: 11-22-22 Well ID# MW-106D e.,_...
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. C 1 y zuzz
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. Iniri;�:3;d0;1 ?�•7.-•�R,,r,,;., h.,;,
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft. ✓�^tr%jjj 7
Physical Address,City,and Zip
21.REMARKS
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: I
(if well field,one lat/long is sufficient) I
35.414179 N -80.805671 W
Signature ofCertttied Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form,1 hereby certify that the wet/(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100{fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well oumer.
If lhis is a repair,fill out known well construction information and explain rile nature of the
repair under z21 remarks section or on the back oJ7his form. 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.
For nultiple ii jection or non-uvater.supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 77 24a. For All Wells: Submit this form within 30 days of completion of well
For nmhiple wells list all depihs ifdijJerenl(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"-" - 1617 Mail Service Celll ter,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: H SA construction to the following: I
(i.e.auger,rotary,cable,direct push,eta) I }
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t ,
13a.Yield(gpm) Method of test
24c.For Water Supply&Injection Wells:
for in'submit one copy of this fom within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health'department of the county where
constructed.
Form GW-1 North Carolina Department crEnvironment and Natural Resources-Division of Water Resources Revised August 2013