GW1-2022-00124_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD For internal Use ONLY: i
This form 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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul&cased wells OR LINER if a licable
FROM TO DIAMETERT TMCtCVESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16."INNER CASING OR TUBING eothermal closed-loop)
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 1 60 It. 2 1O' SCh40 PVC
List all applicable ire/l permits(i.e.County,State,Variance,h jection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 60 ft. 70 ft. 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
:FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well:
ft. f[. i
(Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.STAND/GRAVEL PACK if applicable)
FROM TO I1IATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier ft. ft.
❑Aquifer Test ❑Storrnwater Drainage
f[. 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 siu,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
11-21-22 MW-107D ft. ft. ^: - K " J.
4.Date Well(s)Completed: Well ID# ft. ft. 6-' ' J.`t dz,
5a.Well Location: ft. ft. l-
Colonial Pipeline Company ft. ft. „^-
Facility/Owner Name Facility ID#(if applicable) ft. ft. r y M1 f.-� �� " l ik
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. ft.
Physical Address,City,and Zip 11.REMARKS
Mecklenburg WELL WILL NOT BE SANDED OR GROUTED IN AT THIS TIME.
County Parcel Identification No.(PIN) SCREEN AND CASING ONLY FOR RECOVERY PUMP.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.414791 N -80.806315 W DW
J a
Sigirlature of Certified Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the hell(.)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
1f this is a repair,fill out known we//construction information and explain the nature of the
repair under=21 remarks section or at the back of this 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 multiple injection or non-crater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 77 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'difjerem(example-3 a 200'and 2 c@r 100') construction to the following_
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"-" 1617 Mail Service Ce'ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form Athin 30 days of completion of well
12.Well construction method: HSA construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) h
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceti ter,Raleigh,NC 27699-1636
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection(Wells:
v
Also submit one copy of this fornr within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health!department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013