GW1-2022-06681_Well Construction - GW1_20220708

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WELL CONSTRUCTION RECORD Forin�inal Use ONLY:
Tlils form cube used for single or rmrltiple wells. ,
1.wdl Contractor Informations
4
Shane Gossett DESCR
well counacrorNamo 45 fL 4li ft. ! 15gpm '
195 -ft196; ft. 479Pm
3528-A i
NC Well Contractor Certtfieadon Number FROM' 7O nzs ,j
McColl Brothers,'Inc. a b• 3a .ft•.. 8 ' In. 0.25 Galvaniie steel
Company Name MEN FRM—
to Tr688I MATERIAL,
z.Wa C,06str•acaton Permit#:. 12965 ft.
List all appieable well amratruc8an permits(Le.County.State.Variance,etc.)
f'
3,well Use(check iveh use): i
Water Supply well. t . ft. ft,oAgiicultural . DMmridpallRtblic
acothermal(Heating/Cooling Supply) DResidetttial Water Supply(single) ;
O ustriavcommercw OResidential Water Supply(shared) VMROU• To MA a o
(jojr 0 20 R+ ec n is Pour from sprface•8001b5 i
Non-Water Supply Well: ft. I
OMorrftoriag ORe ewery
'echon Wele ,
OAquft Rechmp. OCaoundwatea RemeditrtlonMUM I!. I E
DAquifdr Storage and Recovezy OSalimty Barrier Br ft.s i
OAquilferTest OStorarwaterDmivage
DELI Technology DSvbsidence Co ttmi j
DGeotltem:al(Closed Loop) OTra<xt FRons ao DlcscroR sbnn '� ;
OOeolheznzal t Cook Retom OOdw. lainunder#21 Remarks 0 R• 15. ft- �' Red claK
16 ft' 30 % Granite ; 4
4.Date Weli(s)Completedt 6/17/2022 31 L 200 •ft, ! Granite
S.Well Location 301. k• 500 D• .Granite
Chandler commons 5oi fl-. 100 . ft. Granite.
E,
Facw1owtter Name Facllhy]I3#(if applicable)' tj, i
916 blu central rd Pineville nc28134
Phgs W Addtws;City,and zip j
Mecklenburg 205-112=83 seemed'to•5oo' 'with a
Comity Parcel Idemiticadon No.(PIN) �f�. -!` ••a s,.M I
5b:Latitude and Longkode in.degr w1minuteslsecouds or decimal degrees: 22.CeMeadou: J i J L (�I
(ifweu llcld,'one ladiong is sufficient) .0 S 2022 6/22/2022, i
35006'44.4132" N 80053'20.6088 ..w + .•
yv r t.L.r�.,.J.l:.
' .. i ,'Si�Bt<a8 Of CertfBed we11 EonC80 or ;✓L�c�{'C;(� � -
6.TS(are)'thew ens or OTemporary "BY idgrIng gda form,l hereby certify that rile MIA,B),was.(wero)coiuttncte¢hi accordance.
,015A'NCAC 02, 'X740 or 13A NCAC Mc ma well commwdod smadar&and Owe;
7.7s this a repair to an existing 3411: Oyes o•NO copy of ft word has beery prodded to Ae well owrt f- ;
If this la a repah;iiU out known rvel(corauruction biJormatloa a»d explain the nawr4 bf the 23,Site diagram or additional WA tleteft
repair tmder#21 rema*section or as the back of this farht: You May ude Me back of this•pegs t01>�• Addttionat weal'she deaaik ot!wW j
8.Number of wells constructed: 1 contraction details. You may also attachadrii, 7d patio Rom'•• .
For multiple injection or non-water supply weWONLY whh the fame 00w&negah you can
submJt uric farm 24.Submittal meat WOne:
600 ( ) 2,41 Pw All wells: Submit.ihis,iNm withht 30 days pf cozpple>ion•of well;
9.Total oval depth below land surface: 1
Formuhiple wags liar all depths(l'dprem(example-30200-and 2 0100) coz:stracdon to'the fonowirig i
10.Smtic water level below top of casing: 30 (ft.) Division of Water Quality,Idoriloation Proccuing Unit,
1617 Man 5areice t7errter,Raleigh,NC 276994617.
If water lewi Is above cueing,use"+"
$ 24b. or ial Lion ovals: tn.addition to 'the tbmr to the address in'24a f
11,Borehole diameter., (1nJ, above,also subttdt a copy'of thislfoim Mittin�.3Q days of cxirapladon of wells
1Z.WeD•cogstraetiou method: Air rotdrY' conmuction to the foliowing
(ie.sues*,raaa9,able,erect push sae) Division of Water Qaahlty,Ut4dergmadd Injection Control Program,
1636 Mell•Sea'eiCl:'Center'r Ra ,NC$7699.1636' ,: • ',
13.FOR WATER SUPPLY WELLS ONLY:
Al lift Zoe.$or Wa*.e:'Sum Iv 8a QeoLr, nna Wgj addition to seadipg t�4pztn toj
13.a.Yield(gpm).__ .—62 ... Method of test,_ ttte ad* s(es).above, also submit one of Ois,foam.vPithin.3ti days of
Of
20outices completion of wag const adion`to the � health department I
13b.Disinfection type: Hth Amonzrt: where cortstrpcted I
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NorthCambnaDeParturontofEHV1°nmantandNaaualltosomces—DivlsiaQofWateiQtmliiy p .