GW1-2021-02529_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or.multiple wells
1..Well Contractor Information:
SOShane Gossett p's O� FROM TO DESCRtPTION
Well Contractor Name q 1 W 260 ft- 262 ft- 15gpm
3528-A 11't ft. tt.
ra,�i�fJ
NC Well Contractor Certification Number Iqt{Oif;3 t'0. c .^YtOB FROM �ro nu�fETER Tint�cNEss uAxER>►I
McCall Brothers, Inc. © '1' 1 ft. 186 ft. 6.25 in. 0.25 steel
Company Name t ,
FROM TO DTAMETER T1tICKNRSS MATERIAL
2.Well Construction Permit#: Eh20-00713 0 ft. ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): z 11
Water Supply Well: FROM TO DIAMETER SLOT SIM THICKNESS MATERIAL
❑Agricultural ❑ umcipaMblic 0 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
01ndustrial/Commetcial ❑ResidenlW Water Supply(Shared) 1 flR ' TO MATERIAL EMPLICEMExThrBTHOD&AMOUNT "
Irrigation❑ 0 ft. 186 ft. o an trimmlerout f grom bottom to
Non-Water Supply Well: ft. ft. cement.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation a tf`fe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERiAI. EMPLAC$MRNT METHOD
0 ft, ft.
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control '
❑Geothemhal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardn anil/rock a ft etc.
❑Geothermal(Hcatin Coolin Return) 00ther(explain under#21 Rcmattts 0 ft. 25 ft. ! red clay
5 4/2021 26 ft, 175 lt. saperlite
4.Date Well(s)Completed: 176 ft- 200 ft- granite
5.Well Location: 201 rt. 300 ft. granite
earnest estates ft. ft.
Facility/Owner Name Facility lD#(if applicable)
ft. ft.
7678 Katherine Dr Denver nc fr. rt.
Physical Address,City,and Zip -
Lincoln
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wall field,one lat/long is sufficient)
35030'58.4784" N 80059'42.2304"1 W " 5/7/2021
Signature of Certified Well Contractor i Date
6.Is(are)the wermanent or ❑Temporary By signing this fonm,I hereby certify that 4he wells)was(were)cotuttucted in accordance
140ewith 15A NCAC 02C.0100 or 15A NCAC 02C..0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 00NO I copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the t),ature 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the Sadie construction,you can
submit one fond. 24.Submittal Instructions:
9.TOUtI well depth below land surface; 300 (ff.) 24a. For AR Wells: Submit this firm within 30 days of completion of well
ror multiple wells list all depths(f dilJerem(example-3@200'and 2@ 1001 I construction to the.following:
10.Static water level below top of casing: 30 (ft.) Division of Writer Quality,Ulforuuttion Processing Unit,
If water level is above,casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
� i i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the foim 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.) I
Division of Water Quality,Underground'`Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 if Service Cent'I Raleigh,NC 27699-1636
13a Yield(gpro) 15 Method of test: all lift 24c.For Water Sumrly&C,eo(berm Ai Weila: In addition to sending the fond to
the addtess(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: hth Amount: 20o ices completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qua o lity Revised Jan.2013
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