GW1-2021-06829_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD I For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ?
y 14.WATER ZONES
Shane Gossett .FROM TO I DFSCRIPTION
Well Contractor Nit nic nup 1 9 400 ft- 401 ft. ? 17gpm
3528-A rS ft�U'tSlt rt. rL
r{e�.t
NC Wc1l Contmdor Certification Number s',n 1 f' I5..OUTER CASING for multi cased dells)OR L]NER it ii licable
3 .V�ta Jo 110� FROM TO DIAM1tETER TIIIC.KNESS MATERIAL
McCall Brothers, Inc. 1 ft. 119 ft. 1 6.25 in. 1 0.25 pvc
Company Name 16.INNER CASING,OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 11779 0 ft. ft. in.
List all applicable well construction pennits(i.e.County.Susie.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO I DIAMETER it SLOTS17E I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. ft. in,
❑Geothcnmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑ idustrial/Commercial ❑Residential Water Supply(shared) e.GROUT
FROM TO MATFRIAL EMPLACEMENTMETHOD&AMOUNT
m ttion 0 ft. 1 119 ft. Portland trimmie grout from bottom to
Non-Water Supply Well: ft.
too 3000lbs
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rt applicable)
FROM TO MATERIAL I F,MPt.ACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑Slonmvatcr Dmrinage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additinnalsheets if necescary
❑Gcolhemral(Closed Loop) ❑Tracer FROM TO DESCRIPTION(calnr,harrhrees,snil/mcklrte,gritinsize,etc.
❑Crothetmal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 ft. 25 ft- red clay
26 ft, 80 R. sandy clay
4.Date Well(s)Completed:
3 18 2021
81 ft- 90 ft• loose saperlite
5.Well Location: 91 ft. 200 ft. granite
ITiSM 201 ft. 420 ft. granite with quartz stringers
Facility/Oi%ner Name Facility ID#(if applicable) ft. ft.
813 Jefferson Dr Charlotte nc ft. ft.
Physical Address.City,and Zip 21 REMARKS
Mecklenburg
County Parcel identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifiscll field.one latAong is sufficient)
35008'59.82" N 80047'05.604" W 4/1/2021
Signature of Certified Well Contractor Date
6.IS(sire)the u'Cl rrnanCnt Or ❑Temporary By signing this Joan,I hereby certify tlmt'the it-ell(s)rams(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair t0 an existing%fell" ❑Yes o•Nct copy of ilris recorel has been ptmrided to the well mener.
1f this is a repain.(ill out knoun well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to proxide 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 nan-crater.supph•wells ONLY with the snore construction,ion can
submit one form. 24.Submittal instructions:
9.Total well depth below land surface: 420 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mdtiple a ells list all depths ff tli(ferew(example-3@200'and 2@ 100') cotlstmction to the following:
10.Static water level below top of casing: 30 (It.) Division of Water Quality,Information Processing Unit,
If water level is above,cawing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I
1].Borehole diameter.
6 24b.Fur infection Wells: In addition Ito sending the form to the address in 24a
(ire•)
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 puslr,etc.)
Division of Water Quality,Undergriound injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen ter,Raleigh,NC 27699-1636
air lift 24c.For Water Supply&Geothermal Wells: III addition to sending the fonn to
13a.Yield(gpm) 17 Method of test: the addresses) above, also submit one copy of this fonn within 30 days of
hth Amount: 12ounces completion of well construction to file!county health department of the county
13b.Disinfection type: where constructed.
j
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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