GW1-2022-07515_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett BROM 0' TO+w-+ DESCRD?170N '
Well Contractor Name N. y- 230 ft- 231 ft- 15gpm
3528-A 1 f 1 2022 120 ft- 121 ft. 5gpm
NC Weil Contractor Certification Number P. }_ : 'K0:0 'S . t
FROM TO DIAMETER THICKNEss MATERIAL
McCall Brothers, Inc. 1 ;� � �'rh< R-9 utlq .1 ft- 57 ft- 6.25 In. 0.25 Pic
Company Name ' B1bl. el m
FROM TO DIAMETER THICK"M MATERIAL
2.Well Construction Permit#: 10012597 0 ft. ft. in.
Lis(all applicable tvell'construction permits(Le.County,State-Variance,etc.) ft. ft. m
3.Well Use(check well use):
Water$UpplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL i
ft. ft. in.
❑Agricultural ❑ umcipal/Public
❑Geothermal(Fleating/Cooling Supply) .4esidential Water Supply(single) ft. rL m•
❑lndustrial/Commercial ❑Residential Water Supply(shared) $` 0`
FROM TO MATERIAL EMNACEMENT METHOD&AMOUNT
❑Irri Lion 0 ft. 20 •ft- en one pour from surface 1300lbs
Non-Water Supply Well: chips
I ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundivater Remediation A
FROM TO I MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑Stomtwater Drainage
❑Experimental Technology ❑Subsidence Control n
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRFMON color,bardnM millrock tM grain ft etc
❑Geothetmalggatin Cooli Retum) ❑Other(explain under#21 Remarks) 0 ft. 25 ft- Red clay
8/8/2022 26 ft* 40 ft' Sand
4.Date Well(s)Completed: 41 fl, 48 ft. Rocky sand
5.Well Location: 49 ft. 60 ft. Granite
Jack Bradshaw 61 ft- 100 ft' Granite
Facility/Cramer Name Facility ID#(if applicable)
101 ft• 240' ft- Granite
13828 point lookout rd Charlotte nc rt. rt
Physical Address,City,and Zip ;
Mecklenburg
County Parcel Identification No.(PIN) i
5tm.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one IaUlong is sufficient)
8/9/2022
35007'24.9636" N 81001'40.638" w
Signature of Certified Well Contractor Date
6.Is(ire)the twaneut or ❑Temporary 11y signing this form,I hereby cer16 that the well(s)was(were)constructed in acconzlance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that o
NO copy of this recant has been provided to the well owner.
7.La this a repair to an existing well: ❑Yes o•
1f this is a repah;fill out known well construction information and eaplain the nature of the
repair under#21 remarks section or on the back of this form. You
Siteu may u.use the diagramor additional well details:
Yohe back of this page to provide additional well site details or well
S.Number of wells consKr•ucted: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or nan-water supply wells ONLY with the same construction•you can
24.Submittal instructions:
submit one form.
9.Total well depth below land surface: 240 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@I001 construction to(he following:
I �
10.Static water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit, i
If water level is above casing,use.••+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:
6 On.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: Air rotary construction to the following:
(i.e.auger,rotary,cable,direct print,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
20 Method of test.
13a.Yield(gpm) the address(es)above, also submit one copy of this form within 30 days of
Hth Amount: 12 completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Emdromment and Natural Resources-Division of Water(Quality Revised Jan.2013
i.,