GW1-2022-07453_Well Construction - GW1_20220810

'OLL CONSTRUCTION RECORD Far baertm]useotdlY:
Z ids form can be used for single or multiple wells '
i
1;Well Contractor Information:
Shane Gossett r--; � 41ED MM �o yDss ox
WellCoaOaomrName — �^ 140 ff 141 ft- [ 20gpm
3528-A A��r, 'Z�ZZ 150 ft• 151 �• i 20gpm
N6 Well Cofactor CcrtifiCstien Number ; a. Urtd ply TO DrAata�e. ]rtw
McCall Br0#hekS, Inc. {nE�;P�'`r��,a;�i'� 1 tt• 115 ft,. 6.25' �• 0.25 Pvc
Company Name I
13887 FROM To olAnaa,Talt �vsss MAT6RiAI.. .
2.Well Construction permit#: 0 ft ft.
Lisi all applicable well twnsmicdon permits(Le,County,State,Yarlance,etc.)
ft. ft..
3.Well Use(check well use): I
Water Supply Wen: 1moM To Dwt�t�lt SLOTM I UT1fltarltess MATEarAIL
pAgr9ctrttttral O umcipalIPublic. 0' ft• ft. in
❑Geothermal(Hasong/Cooling Supply) residential Water Supply(single) fa ft. �• '. -'
Qlnduskiaycot anwW al OResld'endal Water Supply(shared) 1+aoM To A4AT131t1A taslarelt r a ' ova
.131rdgation 0 & 20 ft ' eChips
is e .Pour from surface 1501b9
Non-Water Supply Well: & ft.
OMonitoring ORecovery
Iryection 411: ft. ft..
t7Aquifer•Rechayge OGroundwater'Remedladon
fec.Storage and Recove OSalini Barrier o Mr, �
O
n tY 0 ft. ft.
❑Aqui£erTest OStomtwaterDrainage ft h. ,
pExpeiimetttal Technology OSubsidence Control
❑Geotlwunal(Closed Loop) OTracer sttoM To DISCRUTrox enter f wreck ell.
At3oodmml(fieadn Cobli Return OOther Le2lain under#21 Remarks 0 ft• '25 ft. Red clay
26 ft. so ft. Sandy clay
4..t1•ate Wen(s)Completed: 7/11/2022
81 ft• 100 ft. Rocky clay
S:Well location:
1•01 fL 150 ft. Granite
Debbie Murray 151 ft' '200 fL 'Quartz and mlka
FactlftylbwnerNam Factity]DH.(ifapplicable)
335 chestnut ridge rd kings mountain nc ft
Physical Address,City,and'7ap
Gaston ,
County Parcel ldentffieadonNo.(PRN)
Sb.Latitude and Longitude in degreeslminuteslsecoads or deciutal degrees: 22.Certification:'
(if-well field,one Wftag is sufficient) II
3.5a16'22.4724" N 81'20'11.4648" qt /zo/zozz .
Si�ahtm of Certified 4VeA Coaaactor Date
r),Is(are)the rtnaneat or OTemporary By algtdng this form,I hereby ea i&that the well(s)was(were)constructed in aceordhfi
whh 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Constniedm Stondmdi dud thm
7.Is this a ftpair to an existing well: Dyes•00No 'copy of this record has been provided to ire well odner.
/f.t4p Is a mptdr,fill out knorm well con0ruction ir](omwtlon mtd explain the nature of the
repair under t121 mmarks section or an the back of this form. 23.Site diagram or additional well de4aiis: '
You may use the back of tifis'page to provide additional well site dean or well
8.Number of weiis.constructed: 1 constmcdoA details.You may also attaeh additional pages if necessary. ,
rai muk4de injecdon or non-water supply wefts ONLY with the samn eansVuedan,you can'
: .cttLinh one form. 24.Submittal Instructions:
y.Total.weil depth,below land surface: 200 0.) 24&For All Wells Submit ft form.withht:30 days'of completion of well
par muhiple wells list all depihs j(dfffirent{example.30200'and 2 f01007 construction to the fhnowhW.
10.Static water level below top of casing; 20. (ft,) : Division of Water Qoailty,Wormation Processing Unit, i
(f water level is above casing',are a" 1617 Mail Service Center,Raleigh,NC 27499-101.7
1i.Borehole diameter: 6 (i».) 24b.For ectlon Wells: In sddifion.to sending the form%u ttie address in 149
-above, also submit a c M.of."form within 30 days of otmtpietion of 611
12.Well construction method: AV rotary construedonto thofoliowhtg:
(ie.auger,rotary,cable direct paste,etc.) Division of Water Quality,Uddem"Ad Injec8ott Contmi Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scrviec Ctditet;Ratetgh,'14C 17699.16M I
. Air lift ?Ac.For Water 3rmttts&Geothe kal Wells: bi edditlon to sendmg The-form to
13a.Yield(gpm) 40. Method of test: the address(es)above, also submit one copy of this foil wldiin 30,dugs
13b.DisiDfeedontype: Hth Amount. 20ounCes completion of well oonsWarion to the`county.heaith department of the dont�y', `
wh=constructed. o-
Fopn G9��1 NoithC=EmaDepaMmtofEnvimu=ntmANamm]Rcmm=-:Divisionef WaturQu�aifly Revised lea�013