GW1-2022-07454_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD Forlluemsl Use ONLY:
This form can be bsed for single or multfple'wells
1'.Well Contractor lnfomation:
Shane Gossett :Rota nss ox
WcllCoattactorName120 R• 121 ft. 25gprr
: 3528=A
NC WellCo*tacwrCettificatiouNumbec .' Uric TO DMIN a 1fficKItBss NA7Ear,►L r
:McCall Brothers, Inc. litt�rt�- duOG 1 ft' 96 ft. b.25 In. 0.25. Pvc '.
&rr.janq Name• FROM TO DRIOMM MATKRM
: 2 well Constracttott Permit : 13888 it. ft. Via•
,Ug all applicable well co»squcnon pennds(La.County•Stole.Varlanca etc.) 0 ft, ft.:
I Well Use(cbdckwell use):
Water Supply.Well: FROM TO � DiAMEM :A OFMZ8 TH1139aw MAMIAL �
.MAgricultHrai. O ulkipaUPablic
: O.Geothennal(Heating/Cooling Supply) aesidential Water Supply(single) It ft. bt.
Olndttsuiaf/Commercial 'OResidential Water Supply(sad) 1ttbDM idA +�AM
en n e '
❑ ton 0 ft. 20 R• chips Pour from surface 7501bs
Non-water steeply wen: ft.
OMonitoring ORecovery
action well; ft. ft,
l7AquiferRccbmge ❑GaroundwaterRemediation•
91O tNA't:t2 n
oAquifer Storage and Recovely OSaffnity Barder 0 R, ft,
OAquiferTe'st ft.
OStomhwater])raiDagO
OEVedmemal Technology OSubsidence Coattof
OGeottemral(Closed•Loop) OTracer Tm"M To DffiCsWMINq N.2br hadoem mahnck ae
taGeothetmal(Heatin Cooli Return Otkher.( under#21 Remarks 0 •R' 25 ft• Red clay'
26 fL .50 f Saperilte
4.Date Wells)Completed: 7/7/2022
51 it. 8t) ft, Rocky.clay.
5.Veil Location: 81 ' fL 100 ft• Granite I
Shirley Cobb _ mi D• 200 X Granite
Facllity/otvaer Name Facility IDS(if applicable) % ft.
333 chestnut ridge rd kings mountain ft. ,
�Pbyslcal Addtcss.City,and Zip
Gaston
L'pnn yty Parcel ldontffication No.lP1N)
i
5b.Latitude and Longitude is degrmhu rotes/seconds or decimal degrees: 22.Certification:
Orwell Geld,one la(/long is sufficient) j
3501621.4896" 81°20'11.5008 W �j�1/ 7/20/2022
Stgaatme of Cettf W WOO Contractor Date i
6.Is(are)thew' ent or 'OTemporarp By-Oguing Arts fonn,f hereby.cer0 that the wells)was(were)constructed 0 acco"ce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard:and that a
I.is this a repair to an esisdng well: Oyes o•No copy efthis record has been provided to the roll owner. .
If rids is a repair,fill out known well construction info m:don and explain the nature of the diagram or additional Well(1t:ta782 '
rep dr under#21 remarkr suction or on the back of thls form. •Site
Yon may use the back of this page to provide additional well site details or wo
X.Number of-wells constructed: 1 conaruction details. You may also attach additional pages if necessary
For.multipleO#ecxdon or,non-water supply wells ONLY with the same cottsirttc#on,you can
:.'rotintttane form 24.Submittal IDOvellonsi
9,Totatwell depth below,land sarfaee: 200 00 24a. For All wells: Submit this fbmt.within 30 days of completion of U
Formuldple tveTla ltataTi depths()d(hrrent(example•3Cd200'and 2CtDi00y CDna{]aCtion to the hllowirlg .
10.Static water level below.top of casing: 30 (ft.) ' Dlvfslon of Water Qoaltt ,Information Pr ecessing•Uu%
lfwater level is above gastng,use + 1617 Mall Service Center,R'slelgh,NC 27699-1617
6 24b.Rot Injection w ls: ht addfidon to,.sending the fomh to tlte'addr�ass in 2
11.Uorcbole diameter: (lttJ:
above; also submit a copy of tins form within 30 days of comphrtiori of we '
12.Wen construction method; Air rotary constntclimto thefoti0Vvlug:
(i.e.auger,rataty,cable direct paste ate) Division of water Quality,Unde>round Igjection Central Program, I
13.FOR WATER SIIPPLXwELLS ONLY: 1636 Mail Service CentW,!Ral 4%NC 27699.1636 }
Airlift 24c.For watm'tuMy&Geotbe_I i Weil$: InadditioiLtotiendittgthefoamto
13a.Yield(gpm) 25 Method of the addresses)above, also submit one copy Of this fdrm within ab`days'of
Hth Amount 20ounces completion of wen construction to'the county health department of the courtly
13b.Di.stafection type: where conducted.
Fomh GW_I North Carolina Dwaroncut of Envimrmmant and Natural Resewces-Division of Water Quality Revived Jaa 2013
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