GW1-2022-07467_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This formcaa be used ror sink or mr kipte uvIls
1.Well Contractor Information:
:=1i.':WAIERZONES
Shane Gossett mom I DESCREnWN
Well GontracrorName 120. R. 121 % I 5gpm
�.'� !�" Z.t lED
136 M 139 & 45gpm
3528-A '� ;-V
NCWell Nur+der 1St;OfltElC'CI15QiTG eneased•widls t)RtiiNEit tf
FROM To' ffi W DUMBR 71BWKNM MATER
McCall Brothers, Inc. q►) i n 2022 1 M75 fL 6 25 ia- 0.25 Galvanized steel
UnA 46:'Ii�NERCASINGOlE-L1fBII�TG dosedAvo r -
1709 ice' L� FROM To DIAMEM imIC�5 MATERUL
2.Well Construction Permit#: D'R�` 0 n- 81 ft. a 0.25 Pvc `
List all emscable'mr71 consmfafoa Pennits(i.e.Coumn,State.Variance,eta) n I
3.Well Use(check well use): •;17.SCREEN
Water Supply Well: FROM TO s. DIAMETER I SLOTSUE I TERCKNESS" I MATMUAL v11,
,.
GAgricultural r0runkipaMblic 0 ft. IL 6L
O(xwthermal(Heating/Cooling Supply) 4AReskicritiat Water Supply(single)
fY. ti, in.
Ulndustrial/Commercial ❑Residential Water Supply(stored) i8 kOUT
FROM I TO MATERIAL 'EMPLACEME•NTMETH00 AMOUNT
13hrization 0 IL 14 ft. Bentonite 600lbs pour from surface
Non-Water Supply Well: chl' s
0 IL: 81 m Portland Trimmle grout 141lbs
!]Monitoring ORccovcty
ramant
Injection Well: n' n
UAquifer Recharge GGrounduaterRemediation 19 SAND1GRiUVEL'PACK ` le
FROM TO I MATERIAL L'EMPLACEMENT METHOD
UAquifer Storage and Recovery E]Salinity Barrier 0 tG n;
GAquifer Tilt GStorra ater Drainage ft. (L
GEaperim a tat Technology GSubsidence Control
20:DRIfLING'L,OG"a 'ad�6iod�aLstiee[s dotoa�n .,
GGcaodtemlal(Closed Loop) OTracer FROM TO DESICKWTION odor,ter aowmek -eye M)
GGoothermal(Heating/Cooling Rc um) 00ther(cKpbinunder#21 Remadcs) 0 rl. 10 Red clay .
8/2/2022 11 M 65 rt• Course sand
d.Date Welts)Completed: 66 rL 80 ft. Granite
5.Well Lacatwn: 81 rL 100 ft. !Granite-with quartz stringers
Christine bridges 101 fL 200 (L 'Granite with quartz stringers
Facilky/ou-nermuse Fatil'uy IDII(ifappikable)
.1631 'ages mountain rd mooresboro nc rL lL
Phssiwl Addtesa,.Chy.and Zip 2L"REINARE4S
Cleveland
tJoamiy Pamet Iderdifia+rionNo.(PIN)
5b.Latitude and Longitude in dcgrealminut s/seeonds or decimal degrees: 22,Certification:
(if wen field,one laMong is saofficiend)
35012'18.144" N 81040'46.3512" W 8/3/2022
$006 ofCcdilied Well Commior Dare
b.is(arc)the-do ormanent or 01emporarp By ogning rids form 1 kyabv certify rhos lhr mc1Hq was(avre)roman aM in accordance
with 15A NCACO2C..0100 or 15A NCAC 02C.0200 Well C0YWm Y&m Smudardr and chat a
T.Its this a repair to an existing well: Ems O NO cap,of this rowrd has been pmvlded to the mW1<maser,
lfrhis is repair.Jill cwAn~nail csu wrw*?n lnfr»ma(km andegnlain Ow nave of the
relxrir uraler#21 rem#A v ex'asan or nm dre ltmat ofilds from. 23.Site 41Wum-or additional wdl details:'
You may use die back of ft page to provide additional uia Site details oir tech
8.Number of wells constructed: 1 twaslawfign details. You may also attach a"tion d pages if n0cessary.
Far maltljde lirlaer&en ar rrau•mortar sryrld}'utelfs ONI.P Kith tiff mme eow'tiati&rn,3'ou rm+
et+bntitark faun U.Submittal Instructions:
9.Total well&VM below land surface: 200 ( ) Ua. For A" Wells: Submit lids form within 30 days of t ompletion of well r
r'ar multiple mx'lls list all dedtlrs 1(fd(femal tevingW.30200•atd 24100) construction to the fallowilw
10.Static water levd below top of casing: 25 (D•) Division of Water Quality,Information Prom&Unit,
If ftvw land is abo+te cadap ass *" 1617(►f&Servioe Center.Raid& NC 27699-1617
It.Borehole diarueter: 6 (In.) 24b.For iaiection Welly. In addition to sending do form to the address in 2
abo%re Am submit a am of fbig form within 30 drys of compktafn of Melt
IL Well coastruclion methnd: Air rotary rawwmafion to flit foUmrirtg:
0&auger;rsta w.cable,dioef Pak dL) DWkdon of Water Qr dUy.Underground Injection cAntraI Program.
13.FAR WATER SUI MV WE11,1.S ONLY: ld3b MASerT�e Center,>ZaleiSb,NC 2Xi3�9.1Cr36 `
13a.Yield(gpin) 50 Method of hall• Air lift Uc.Far Water Sunnlr&Geothermal Wells: h13ddhiaR to seadin9 the fomr to
The addwWes)above,"submit one t:upy of tblis form within 30`days of
Hth Amonat:. 12ounces Completion of weli eaasarirt otion to'the e�aullty b abb&-pilm�at of the county
13b.Ditinfeetton type: wherecartstnotted. ' I
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