GW1--03737_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For internal Use ONLY:
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 tnul&cased wells OR LINER if a licable
FROAf TO DIAMETER THICI9VESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 26 fl- 2 in. sch40 pvc
List all applicable well permits(i.e.County,Stale,Variance,hyection,etc.)
f[. ft. in.
3.Well Use(check well.use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 26 ft' 46 ft- 2 in. .010 sch40 pvc
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) tr. ft. in.
❑industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD 3i AMOUNT
❑irrigation_ _ _ _ 0- ' -21-- ft._-Portland-Cem=T-remie=--- -- - - --
Non-Water Supply Well:
iJMonitoring ❑Recovery 21 ft- 24 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 24 ft• 46 ft. #1 Sand Tremie
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 size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft•
4.Date Wells corn leted- 9-13-21 Well ID# MW-22R
5a.Well Location: ft. ft. s
Colonial Pipeline Company fr. I. ro iV �n-
Facility/Owner Name Facility iD4(if applicable) y.,
ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078 "�t
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 2 x 2 Pad and 6"Cover
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient) �--� "I ``+�
35.415978 N -80.805282 W ��,� 0 . 2:;- a
Signature of Certified Well Contractor Date
6.is(are)the well(s): IZPermanent or ❑Temporary By signing this Jinn,1 hereby ceriifv that the srell(s)was(were)constructed in accordmice
with ISA 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 ONo copy oj'lhis record has been provided to the well owner.
If this is a repair,fill out known well construction jgfbrnmtion and explain the nature o0he
repair under z21 remarks section or on the back ojihisJirm. 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.
For inuhiple injection or non-crater supply ire/Ls'ONLY with the same construclion,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For intilliple iwells list all depths Y'differein(erantple-3 rr 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
IJ'waier lerel it abo•e casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: in addition to sending the form to the address in
6 1/4 HSA 24aabove. also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to tile 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit 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-
Form GW-I North Carolina Department of Environnient and Natural Resources-Division of Water Resources Revised August 2013