GW1-2021-02517_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonii can be used for single or multiple wells
1.Well Contractor Information:.
Shane Gossett FROM TO DESCRIPTION
Well Contractor,Nanic 191 ft. 192 ft. 2gpm
3528-A
NC Well Contractor Certification Number 15:t1UTER;Cr15lNl"s to�'mUi " aedel" ORIlVER: '' IlcSble :; } ,,,,,,;:i
FROM TO DIAMETER -THICKNESS MATERIAL
McCall Brothers, Inc. 1 rt. 67 e. 6.25 in. .0.25 rove .
Company Name :16:INNER Cl1S1NG'OR'Gl1IB '`dDilltrillole890 °' ~' � a
FROM TO DIAMETER THICKNESS MATE L''
2.Well Construction Permit#: EhW20-07731, .0 f. ft. in.
List all applicable well construction permits(i.'e.Counq•,Suite,Variance:etc.)
3.Well Use(check well use): 1fi �,�$ _SCREENa n ass" r t„
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
it. ft.
❑Agricultural MUlucipaUPublic
❑Geothctmal(Hcaling/Cooling Supply) esidential'Water Supply.(single) ft. ft. is
Ohidustrial/Commcrcial ❑Residential Water Supply(shared) 18IGRUDT s '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrimtion 0 ft. 22 chips ft. en a pour from surface 800lbs '
Non-Water Supply Well:
❑Monitoring ❑Recovcry
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundvvater'Remediation. =19 SANff/GItAiPCII. licsilrte' 'i rs:a
FROM TO I MATERIAL 1 EMPLACEMENT METHOD .
❑Aquifer Storage and Reco,%'cry ❑Salhiily Barrier p rt. tt.''
❑Aquifer Test ❑StonnivaterDMnage
❑Eayerinientai Technology ❑Subsidence Conlrol
':.20.11DRII31N6:LG;atteha80ii1oiafshoa"3t 1fi;
❑Geolhcnnal(Closed Loop) ❑Tracer FROM TO DESCRIMON(cobrhartimets,soluroctt eta)
❑Geothemrnl(Heatin Coolin Return) ❑Other(ex lain under#21 Remarks) 0 ft. 25 ft- Red..day'
4.Date Well(i)Completed: 9/23/2021 ze t3. 60 tt. fight clay
61 ft. 100 ft. Granite
5.Well Location: 101 ft- 300 ft- Speckled,granite
Robert Johnson 301 ft. 600 ft. Speckled granite
Facility/OtcncrNamc Facility TD#(if applicable) ft. ft.
21173 Plainview estates in. Vale nc.
Physical Address.City,and Zip ,
,21'ItEMA3KS
Lincoln NOV 19 grin
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(irirell field..one lat/long issuf6cieni) INFORMATION PROCESSING UNf
35028'27.444" N 81925'25.8852" W J0�` 11/11/2021
Signature of Certified Well Contractor y Date
6.1s(arc)the welillarmanent or ❑Temporary By signing this form,I hereby certify lhat the ivellfs)nuts(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well'Constnktion Standards and that a
7.Is this a repair to an existing well: ❑Yes 00NO copy of this record has been provided io the rdell owner.
If this is a irpair,fill,inn knoim well constniction infdnnntion and explain the nature of the
repair tool er#21 remarks section nr on the/nark,of this fann. 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 addidonal,pages if net:Gssary.
For rnnhiple injection or namanter supply hells ONLY with'the same construction,yarn can
submit ohe jonn,. 24.Submittal Instructions:
9.Total well depth below land surfacc: 600 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of•well
For multiple u•ellt list all depths if different(trample-3@200'and 2@ 100) construction to the following:
10.Static water level belowtop of casing: 35 A) Division of Water Quality,Information Processing Unit;
If water it,vel it above casing,use '+" 1617 Mail Service Center,Raleigh,NC 276"4617
11.Borehole diameter: 6 (in.) 24b..For Infection 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,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 276"-1636'
13a.Yield(gpm) 2 Method of test: Airlift 24c.For t r u ply&Geothermal4ells: In additJoh to sending the form to
the addiess(es)above, also submit on. copy of this form Within 30 days of
20ounces completion of well construction to the'county health department of the county
13b.Disinfection type: Hth Amount: where constructed.
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Form GW-1 Nonli Carolina Department of Emironment and Natural Resources—Division of Water Quality, Revised Jan.2013
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