GW1-2021-02530_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD For iuterrtal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett FROM To DESCRIPTION
Well ContractorName 9 1 �Oq1 265 ft- 266 h• 15gpm
3528-A tdhAy 1 L. �jti�i1 ft. ft.
NCWcll Contractor Certification Number
FROM DIAMETER
McCall Brothers, Inc. 161�011 Opp vq�`�C'C1p0 ft. �i95 ft. 6 5ll tRIOss MATERIAL
Company Name
Eh2O-0O711 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit# 0 ft. ft. in.
List all applicable well construction permits(Le.Counny,State,Variance,etc.) It. !t. 1n
3.Well Use(check well use): r S0 >
Water Supply Well: FROM TO DIAMETER SLOTS= THICKNESS I MATERTAL
❑Aglictdt tu ural ❑ uclpaUPubiic 0 ft, ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) '
FROM To MATERIAL EMPLACEMENTMETROD&AMOUNT
0brigation, 0 ft. 22 IL h�s e pour from surface 800lbs
Non-Water Supply Well: H. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Romediation
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑StomlwaterDrainage ft. ft.
oExperimental Technology ❑Subsidence Control
❑Geotheraal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.lisrdneu.artllm it typp,gmtn ftN tit)
❑Geothermal(Heatin Coolie Return) ❑0ther(explain under 421Rennanlrs) 0 ft. 26 ft• red clay
4.Date Well(s)Completed:
5/12 2021 27 ft* 185 ft, saperlite.
186 ft- 200 ft- granite
5.Well Location:
201 ft. 280 ft. granite
earnest estates ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7670 Katherine Dr Denver nc
Physical Address,City,and Zip .RItA
Lincoln
County Parcel Identification No.(W
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Celtifleation:
(if well field,one lattlong is sufficient)
35e30'58.4748" N 80e59'43.0872" 5/13/2021
Signature of Certit9ed Well Contractor Date
6.Is(are)the welloormanent or ❑Temporary By signing this fonn,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair t0 an existing well: ❑Yes 00NO copy of this record has been provided to the;well owner.
If this is a repair,fill out known well construction information mid explain the nature of the
repair under#21 remarks section or on the back of this fonn. 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 same eonstruction,you can
submit one faun. 24.Submittal instructions:
9•Total well depth below land surface: 280 (ft.) 24a. For All Wells: Submit this firm within 30 days of•completion of well
For multiple wells Iist all depths iftli ferent(example.3@200'and 2@100) consfmctlon to file following:
10.Static water level below tap of casing: 30 (fL) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the addim in 24a
above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: air rotary construction to the following:
(i.e.anger,,rotary,Cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13..FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralcigb,NC 27699-1636
13a.Yield(gpm) 15 Method of test: air lift 24c.For Water Sunnly&Geothermal Wells: In addition to sending the farm to
the addrms(es)above, also submit one 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, i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013