GW1-2021-00055_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
Tltis form can be used for single or mulliplc wells
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1.Well Contractor Information:
'14.WATER ZONES tg ., ';I
Shane Gossett FROM TO I DESCRIPTIO
Wcll Coninctor Name 240 ft- 241 ft I 4gpm
3528-A ft. rut.
NC Well Contractor Certification Number 15.OUTER CASING fofinulti-cmised wills ORLTNER_ "'hcabk
FROM TO DIAMETER!' THI if a
CKNESS MATERIAL
McCall Brothers, Inc. 1 n. 25 ft.
6.25 din. 0.25 Pvc
Company Namc .16.INNER CASING OR'. ING! ibttic'r`mel tl6Ted4db 7�;k %
10012429 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. ft. tin.
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. ft. in.
❑Gcolhenbal(HcatinCoolin Supply) ❑Residential Waters ft. rut• in.
S/ g PP1) uPPh'(single)
❑ dustrial/Commcrcial OResidcntial Water Supply(shared) 10 GROUT . ."
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
rri ation 0 ft. 25 ft, en onl a 6501bs
Non-Water SupplyWell: chips
OMonitoring ❑Recovery
Injection Well: ft. ft.
OAquifcrRccharge OGmundvvalcrRcmedialion •19.SAND/GRAVEL`PAGK'rfi'i'lickble Rµ-
.
❑Aquifer Storage and Recovery FROM TO MATERIAL I EMPLACEMENT METHOD
❑Salinity Barrier 0 4. ft.
OAquifcr Tcst ❑Stornmatcr Drainage t. ft.
OExperinmenial Technology OSubsidence Control
20 DRILL'ING'1:OG attecli>tAdIt10O81r311e/ri If 000CS3flr1 4ti, * '_::
OGeothcoal(Closed Loop) OTraccr FROM I TO DESCRIPTION color,hardrim.soillrock type,grain sbc,etc.)
OGcolhcmual(Hcatin Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft• 13 ft-
Red clay
4.Date Well(s)Completed:
10/12''2021 14 ft* 100 ft. Granite
101 fi- 300 ft- !Granite with quartz stringers
5.Well Location: 301 ft' 500 ft- Granite with quartz stringers
Charter properties 501 fi- 700 ft• Granite with quartz stringers
Facilit/Owner Name Facility ID#(if applicable) ft. ft.
3808 Johnston Oehler Rd. Charlotte nc 28269
Physical Address.City.and Zip 21 REMARKS;
,Mecklenburg
Count- Parcel Identificatlon No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one Ia1/long is suffrcicnt) nn �� � p�yl{SECTION
35°21'59.454" N 80°46'10.9128" W x/ FUSING UNi, 10/14/2021
Signature of Cenified W I ctor Date
6.Is(arc)the e'el tTnanent or ❑Temporary By signing this fort,1 hereby certify tha('the neU(s)was(were)constructed in accordance
with I SA NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes o•No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and e-rplain the nature of the
repair under#21 remarks section or an 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 iron-water supply wells ONLY with the same construction.yotr can
submit one firm. 24.Submittal Instructions: j
9.Total well depth below land surface: 700 (ftJ 24a. For All Wells: Submit this torn within 30 days of completion of well
For multiple n•ells list all depths if rlii ferem(example-3@200'and 2@ 100) construction to the following:
10.Static water level below top or casing: 35 (ft.) Division of Water Quality,'Information Processing Unit,
If water level is above casing,use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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.rotor.cable,direct push etc.) Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air lift 24c,For Water Sunnly&Geothermal Wells: In addition to sending the form to
the address(cs) above, also submit lone 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. li
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Q atlity Revised Jan.2013