GW1-2021-00429_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 I To DESCRIPTION
Well Contractor Name 225 ft- 226 ft. 4gprh
3528-A 465 ft, 466 ft- 6gpm
qgjnlfi��main
NC Well Contractor Certification lhrmbcr0 0
FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 It. 137 ft. 6.25 in. 0.25 Pvc
ZFROMI
Coiupany,Namc =DUMTER
THICKNESS MATERIAL
2.WellConstractionPermit#: EI1W21-05841 in.
list all applicable ivell construction permits(Le.Counp;State,Variance,eta) �3.WellUse(ebeckwell use):Water Supply Well: SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑MunicipaMblic 0 fo
ft. it.
❑Geothermal g! ng Supply) Supply(single) ft. ft in.
(Heaiin eating/Cooling S I ❑Residential Water Su 1 sin le
4dustrial/Commercial ❑Residential Water Supply(shared) a ROIl1
FROM TO MATERIAL EMPiACEMENT METHOD&AMOUNT
MArigation 0 ft. 22 ft. en one Pour from surface 900lbs
Tti►iti-Water-Supply-Well: -- - chi s
ft. ft.
❑Monitoring' ®Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation �
❑Aq FROM TO MATERIAL FMPLACF"FrMETHODuifer Storage and Recovery ❑Salinity Barrier tt, ft.
❑Aquifer Test ❑Stor m.vater Drainage
❑Experimental Technology ❑Subsidence Control 0
2DRtSilffiR9" . kiOUi n c
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Color,barsinas soniIra tylie,plan ft etc
❑Geothermal(licatin Coolie Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. Red clay
26 ft- 300 ft. Sandy clay ,
4.Date Well(s)Completed:,'
ompleted: 11/12/2021 lot ft- 128 I'L Rocky clay
5.Well Location: 129 ft- '300 ft- Granite
Megan long 301 ft. Soo ft. Granite
Facility/Owner Name Facility]D#(if applicable)
501 ft- 680 ft- Granite with quartz stringers
2862'lipp6rds creek in lincolnton nc rr.
Physical Address,City,and Zip
Lincoln 0 lull
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in de ec/minutes/seconds or decimal d y "
(ifivell field,one lal/long iistsuffieien[) degrees: 22.Certification: rprom,MrION ii10�E3�St1iG IJNiT
35031'21.6804" N 81008'40.0880 W A), 11/z3/zozi '
Signatum of Certified Well Contractor Dare
6.Is(are)thew e rmanent or ❑Temporary By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes -ONO copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain tire native 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 mtdliple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 680 (ft,) '24a. For All Wells: Submit this form within 30 days of completion of well
For multiple)veils list all depths{fdijperent(example.3D200'and 2 @.100') construction to the following..
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit;
Ij)vatcr level Is above casing,use"t" 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 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,cabiq direct pusi>,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
Air lift
10 Method of test 24c.For Water Smnply&Geothe I sd Welia: In addition to sending the form to
13a.Yield(gpm) the address(es)above, also submit i one copy of this form within 30 days of
Nth Amount: 35 ounces completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
North Carolina Department of Etn*inintnent and Natural Resources—Division of Watcr Quality Revised Jan.2013