GW1--03751_Well Construction - GW1_20230602

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Wel I Contractor Name 30 ft. 45 ft. Wet
3367 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING geothermal closed-log
FROM I TO I DIAMETER THIC"ESS MATERIAL
2.Well Construction Permit#: 0 rr. 15 ft. 2 i"' I SCh40 pvc
List all applicable well permits(i.e.C'ounly,Stale,Variance,I iection,etc.)
f[. fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 45 ft. 2 in. .010 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
oirrigation _ _ _ _ 0_--ft. 11--_ ft.-_-Portland Gem Tremie -- ----- - -
Non-Water Supply Well:
11 ft- 13 ft- Bentonite Chi Tremie
EMonitoring ❑Recovery
Injection Well: ft. fr. Bentonite Chi Tremie
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 ft• 45 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck type,gimin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
7-29-22 MW-03R ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Colonial Pipeline Company ft. ft. 1
.,��•�;mot F.I �
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 ft. fr.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 2 x 2 Pad
County Parcel Identification No.(PIN) 6"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient) 1
35.415661 N -80.806188 �l � _(``��I�`�1J� g • a-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(sere)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy ofthis record has been provided to the well owner.
lrlhis is a repair,fill out known well construction informalion and explain the nature ofthe
repair under+2l remarks section or on the back oflhis join. 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 nndliple injection or non-water supply wells ONLY with the sane construction,you cal
submit one forms. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudlip/e wells list all depths ifdl jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 39 (ft.) Division of Wetter Resources,Information Processing Unit,
1j)raler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA° 2" spoons 24a above, 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 Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply St Injection'Wells:
(gP ) 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 Environment and Natural Resources-Division of Water Resources Revised August 201_