GW1-2021-06989_Well Construction - GW1_20210507

WELL CONSTRUCTION RECORD FOLlntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett PROM I To DESCRrnr,oN
WdlContractorName 235 ft, 237 ft- 50gpm
250 ft. 253 n• 50gpm
3528-A
'OB
NC Well Contractor Certification Number l
t: �R TO
PROM TO D ETER THICKNESS MATERIAL
McCall Brothers, Inc. ft, ft. in.
Company Name FROM TO DIAMETER TIIICIOIM I MATERIAL
2.Well Construction Permit#: EH2O-00706 1 ft. 182 ft- 6.25 to' 0.25 steel
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft ft. In.
3.Well Use(check well use): IIta7:riSE,
Water supply Well: FROM I TO DIAMETER SLOT SIZE THICKN>mSS MATERIAL
0 ft. ft. is
❑Agricultural ❑ umcipal/public
ft. ft.
❑Geothermal(Heating/Cooling Supply) esldential Water Supply(single)
�•
❑Indusirial/Cornmercial ❑Residential Water Supply(Shared) °
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri lion 0 ft, 20 ft, chips
en one 800lbs pour from surface
Non-Water Supply Well: ft. fa
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation / " li
PROM TO 114A'IERiALAI. EMPLACEMENT MSTIIOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑StotmwaterDrainage
❑Experimental Technology ❑Subsidence Control UD ( 'Q aci�aiiliilt ntu"t s t?iiixi
❑Geothenual(Closed Loop) OTracer FROM To DESCRIPTION talon awdnen sudUrock IyK 0140 fn etc.
❑Geothermal(licatin Cooli Return) ❑Other(explain under#21 Remarks) 0 ft. 25 h• red clay i
2.6 ft- 80 ft. sandy clay
4,Date Well(s)Completed: 4/20/2021
81 ft- 170 ft- tight clay
5.Well Location: 171 ft. 200 ft. granite
earnest estates 201 fL 260 ft. granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7667 Sarah Dr Denver nc ft, ft.
Physical Address,City,and Zip ,
Lincoln RECER
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: MAY X 7 20
21
(if well field,one laUtong is sufficient)
35030'57.2004" N 80059'44.3688" W 4 Information Processing Unit a/zuzo2t
Signature of Certified Wo to Dare
6.IS(are)the-,v rmanent or ❑Temporary By signing this form.I hereby certify that the well(s)•was(wen)constructed in accordance
with ISA NCAC 02C.0100 or/SA NCACi(aC.0200"well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 00NO copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. 1>t a
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-water supply wells ONLY with the same construction,you can
24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: 260 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(/'doereat(example-3@200'and 2@.10M construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 On.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: air rotary construction to the following:
(i.e.auger,rotary,cable,direct pusl>,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,lRaldgb,NC 27699.1636
air lift 24c.For Water Sunnly&C thee .nai Welkq In addition to sending the form to
13a.Yield(gpm 100 Method Of test: the address(es)above, also sabmitlone copy of this form within 30 days of
hth Amount' 20ounces completion of well construction to the county health department of the county
13b.Disinfection type: where constructed,
Form GW-1
North Carolina Department of Envimmnent and Natural Resources—Division of Water Qinality Revised Jan.2013