GW1-2021-04166_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can N used for single or multiple wells
1.Well Contractor Information: !
Shane Gossett 1a:wATER oNEs c . . v _'-
FROM TO DESCRIPTION
Well Contractor Name 225 i< 226 ft• Sgpm
3528-A 475 ft- 476 ft. 15gpm
NC Well Contractor Certification Number 15 bU:TER;Ci1.SMG: 6iralti�w3c8fi41s ORd,'1IliERf litrabl ;
FROM I TO DIAMETER THICKNESS MATERM
McCall Brothers, inc. 1 ft- 1 26 ft• 6.25 ;In. 0.25 PVC
Company Namer16 WNERCfiSITTGURIBDIG;'eo` aliclbsedo0 r;Pti�` s
10011644 FROM TO DIAMETER THICKNESS MATERIAL "
2.Well Construction Permit#: 0 ft. ft. in.
List all applicable well construction permits(i.e.County,Stare,Variance.etc.) ft• ft, in.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER I,SLOTS12Z THICKNESS MATERIAL G
❑Agricultural ❑Mturicipal/Public 0 ft.• ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑ dustrial/Commercial ❑Residential Water Supply(shared) 18„GROU1
FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
1 ation 0 ft. 20 ft. Bentor ite Pour from surface 700lbs
Non-Water Supply Well:
❑Monitoring ❑Recovery h. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:- A [C�ItA\YElY*p"'_ �a`7icable t ? a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 ft. ft.
❑AquiferTesl ❑StormwaterDminage ft. ft.
❑ExperimentalTechnology ❑Subsidence Control
8.1)RiLLINCs10G AWth(aildittunatl
❑Geothemual(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hudn sutUrock in ' eta)
❑Gcothemuil(ticatin Coolin Return) ❑Otter(explain under#21 Remarks 0 ft. 12 ft- Red day
5/25/2021 13 fL 100 ft. Granke
4.Date Well(s)Completed: 101 ft 300 n Granite
S.Well Location: 301 ft- 500 It' Granite •�
Warren thune n. ft.
Facility/owner Name Facility 1D#(if applicable)
4910 Carmel park Dr Charlotte tic it rt 1
Physical Address.City.and Zip
•.21JWMARKS R'-.t is ��a-:�:.z, •Ad8�C`•c lit
Mecklenburg fr;3��'•i1`�cr`r;+on
Count Parcel Identification No.(PIN) 14
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field.one lat/long is sufficient
35008'43.1232" N 80°47'40.0308"• 8/27/2021
Signature of Certified Well Contractor Date
6.Is(are)the we4wrmanent or ❑Temporary By signing this font,I hereby certify that the ivell(s)'I was(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 to an existing well: Oyes 0•No copy ofthis record has been provided to the well owner.
if this is it repair,fill out known 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 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 ividn the same construction.you can
submit one jinn: Z4.Submittal Instructions:
9.Total well depth below land surface: 500 (ft,) 2Aa. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example.3@200'and 2@ 100) construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
lfirater level is above casing,use"+" 1617 Mail Service Center,Raleigh,!NC 276994617
i
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.ivell
12.Well construction method: Air rotary construction to the following:
(i.e.auger.rotary.cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 20 Method of test: Alr Ilft 24c.For Water Sumniv&Geotherma]'Wells:` In addition to sending the form to
the address(es)above, also submit one copy iof this form within 30 days of
13b.Disinfection type: Hth Amount: 20ounces completion of well construction to the`county he8lth department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmcnt and Natural Resources—Division of WaterQuality Revised Ian.2013