GW1-2021-01657_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD or Internal Use ONLY;
This form can be used for single or multiple wells �r``V I
1.Well Contractor information: G '
Shane Gossett 91�1A
$� �jFWAA I TO --DESCRIPTION
Well Contractor Name ` Ges� O Y ft- 272 ft- I 50gpm
3528-A �3VDV\ g %O% 278 r{ 280 ft. 5ogpm
NC Well Contractor Certification Number \00 60 . 'U a ti 4e 1 Y4 - rrra"li abtr t"
FROM I TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 57 ft- 6.25 in, 0.25 pvc
Company Name
FROM -TO DIAMETER THICKiVE33 MATERIAL
2.Well Construction Permit#: 13248 0 ft. It. lu•
List all applicable well construction permits(Le.Counq•,State,Variance,etc.) g• {t•
3.Well Use(check well use): Di ��f
Water Supply Well: FROM TO DIAMETER $LOT SIZE THICKNESS MATERIAL
o ft. ft. in.
❑Agiicultutal ❑ unicipal/Public
❑Geothermal(Heating/Cooling Supply) '9JResidential Water Supply(single) ft. rt. in .
❑IndusWal/Commiercial ❑Residential Water Supply(slurred)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0117igation 0 ft' 22 ft- ech�s en 7n pour from surface 700lbs
Non-Water Supply Well: rt. ft.
❑Monitoring ❑Recovery
Injection Well: rt. ft.
OAquiferRecharge ❑GroundwaterRemediationA:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETHOD0 ft ft.
❑Aquifer Test ❑Stommwater.Drainage
❑Experimental Technology ❑Subsidence Control ,WORM
tint
❑Geothermal(Closed Loop) []Tracer FROM TO. DESCRIPTION color hasten miltrock tyK UAW faT.etc
❑Geothermal(Heating/Co oling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft. tight red clay ,
d.;Date Weil(s)Completed:
4 2 2021 11 ft. 25 ft' loose red clay
26 ft- 48 ft- loose saperlite
5.Well Location: 49 ft' 100 ft, granite
Dean,.Carl&Angela ft. ft.
101 200 granite
Facility/OwnerNamc Facility ID#(if applicable) 201 ft- 300 ft, granite
226 stockwood in Stanley nc ft. ft.
Physical Address,City,and Zip
Gaston had to overream casing to grout because ground was unstable. was unable to get
an Inspection because of ood Frida so I self routed well so It wouldn't collapse
County Parcel Identification No.(PIN) a ore Inspector cos a ons e. called an e a message w nspe or
explaining what the situation was and what was being done.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latllong is sufficient) p�
/JQ�� 4/2/2021
35023'58.376" N 8102'6.965" �t i�lU'
Signature of Certified Well Contractor Date
6.Is(are)the wel4ormanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
whir 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes oi.No copy ofthis record has been provided to the well owner.
If this is a repair,fill out*noun well construction information and explain the nature of the
repair under#21 remarks section or an the back of this farm. 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-water supply wells ONLY with the same construction.you can
submit one form. 24.Submittal Instructions:
9.Total well depth below lanai surface: 300 ({t.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{/di//erem(example-3@200'and 2 @ 100) constmction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit, '
lfwater level is above,casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 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 push,etc.)
Division of Water Quality,Uader•ground.injection Control Program,
13,FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: air lift 24c.For Water Sunuiv&Geothermal Well a: In addition to sending the form to
the address(e's)above, alto submit'one copy of this form within 30 days of
13b..Disinfection type: hth Amount: 20ounces completion of well construction to the county health department of the county
where constructed.