GW1-2023-02449_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Ellingworth F4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3367 It. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATER.A.,
Parratt-Wolff, Inc. 0 151 16 . i" Sch40 I pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 85 ft. 4 in. 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 85 "' 90 ft. 4 in. .010 sch40 pvc
tt f. in.
❑Geothermal( eatin Coolin Supply) ❑Residential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 79 ft, Portland Cem Tremie
FOAqwifer
ater Supply Well:
toring ❑Recovery 79 rt. 82 rt• Bentodnite Cl- Tremie
on Well: ft. ft.
Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licableFROM TO MATERIAL EMPLACEMENTMETHOD
fer Storage and Recovery ❑Salinity Barrier
82 rt 98 rt• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 2-16-23 MW-110Ds)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. - -''^� �' ""✓
Colonial Pipeline ft. ft. APR
!► 20
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14131 Huntersville-Concord Road, Huntersville 28078
Physical Address,City,and Zip
21.REMARKS
Meeklenberg 6"Protective Cover installed in a
County Parcel Identification No.(PIN) 2 x 2 concrete pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one[at/long is sufficient)
35.414673 N -80.805736 W Q 13 a
Signature of Cc 'fied Well Contractor Date
6.Is(are)the well(s): 21Permanent or ❑Temporary By signing this fa t,I hereby certth,that the trell(s)ivas(were)constructed in accordance
with 15A NC-AA 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,.'ll out known well construction information and explain the naive of the
repair tinder#21 remarks section or on the back ofthis 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 nmltiple injection or non-water supply wells ONLY with the saute constracliou,I•ou can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 90 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: none (ft) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use••+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8" /6" (in.) 246.For Injection Wells ONLY: In addition to sending the form to the address in
HSA/Air Hammer 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.anger,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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also subunit one copy of this form 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