GW1-2021-00424_Well Construction - GW1_20211206

WELL'CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
.Shane Gossett FROM To DISCRiPTTON
WeUGonhacorName 140 ft 143 ft• 30gpm
3528-A
NC Well Conhactor Certification Number FROAf DIAMETER THI(7a1ESS �RUL
'McCall Brothers., Inc. 1 ft- 57 ft. 6.25 bL 0.25 PVC,
Compai y Name.
303434 FROM To DIAMETER TV3CKNLSS A
2.Well Constmedou Permit#:. 0 ft. ft.
List all applicable well construction permits(i.e.County,State,Variance,elej ff. in
3.Weil Use(check well use):
Water Supply Well: FROM TO D1AME7RR scow TAICRNFSS I MATERIAL.
0 ft. ft, is
❑Agricultural ❑ tmitxpaUPubiic
❑Geothermal(IfeatinglCoolirig Supply) 2esidential Water Supply(single) ft. ft. bi
Olndustria/Commerciai ❑Residential Water Supply(shmd) FROM To MA L xmnACEMWT METfffm&AMOUNT
❑Irrigation 0 ft. 22 ft• nto i e 'Pour from surface 750lbs
Non-Water`SuppTy Well: — chip s
13mon%toring ❑Recovery fa fr. e
Injection Wel•
❑Aquifer Recharge ❑t^sroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERr tt EM4LA titMOD
❑Aquifer Test ❑Stomrwater Draivage ft. A.
❑Lxperimeolal Technology ❑Subsidence Control 0
❑Cseothennal(Closed Loop) ❑Tracer FROM TO DESCREMON color ha ft xdUrock ere
❑Geothermal gkon Cools Return ❑0ther(explain under#21 Reruadcs) 0 ft: 25 ft. Red clay
11/18/2021 26 5o Rocky clay
4.Date Wells)Completed: 51 ft. 100 ft. Granite
5.Well Location: 101 .ft, 180 .ft, Granite
Keystone builder's ft. ft,
Facility/.Owner Name Facility W#(if applicable) ft. %
137 butter cup Dr, Mooresville nc.
Physical Address,City,and Zip
Iredell
County Parcel Identification No.(PIN)
5b.Latitude and Longitude inAegreestminutestwouds or decimal degrees:
(if well field,one laillong is sufficient) 22,Certifi aatiow.
35030'13.0536" N 80°57'24.6276" W A44 11/23i2021
Signature of Certified Wall.Contractor Dare
6.Is(are)the rmanent or ❑Temporary By signing this fonn,l hereby certify ihat'the weii(s)was(were)constructed.in accordance
with 15A NCAC 02C.0100 or 15A NCA60'2C.0200 Well Construction Staddords grid that a
7.B this a repair to ati exist ting.well: ❑Yes o.N0 copy of this record has been provided to the well owner.
if this Is a repair,full out known well construction information and explain the nature of the
iepair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:i
You may use the back of this page to provide additional well site details or well
8.Number of weM constructed: 1 construction details. You may also attach additional pages if ne essmy,
For multiple injection or non-water supply wells ONLY with the same construction,you can
subihit one form.. 24.Submittal Instructions:
9.Total well depth below laud surface: 180 00 24a. For All Wells: Submit this form within 30 days of completion of well
Fo'rmultiple wells Ustall depths jf diJferem(example.30200'aml2@100) Construction to the followitlg:
10.Static water level below top of casing: 20 (ft•) Division of Water Quality,Information Pr)eesdng Unit,
1f water level is above caslag,use.-+" 1617 Mafi Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (n.) 24b.For Injection Wells: hi additiah to sending the form to the address in,24a
above, also submit a. of.this fir
m,tm within 30 days of coipletion•of well
12.Well coustruetionmethod: Air rotary - — C0nSt1UCd0R othefollowing:
(io.auger,rotary,cable,diimot push,etc.) i
Division of Water Quality,Underground Injection Conant Program,
3. ,
1 FOR WATER SUPPLY ONLY: 1636 Mail Service Cer ,fer•,Rddo,'NC 27699.16M ,
13a Yield(gem) 30 Method of test Air lift 24c.For Water Suanly&Geothermal Wells: In addifiion.to sending 0e fonn to
the address(es)above, also submit one.copy of fhis form within 30 days of
13b.Disinfection t♦Te: Hth Amount 20ounces: completion of well construction to the county health department of ft county
where constructed.
Form GW-1 North Carolina Departumt of Bnviroment and NatumlResources-Division of Water Quality Revised jm 4013