GW1-2022-08455_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD �For InteniaI Use ONLY:
This ford can be used for single or multiple wells
1.Well Contractor Information:
O
Shane Gossett FROM WATER ZTONES, DESCRIPTION
Wc]I Contractor Nanic 16.5 ft- 166 ft- 15gom
3528-A ft. ft. ell,s) 1!�LIN R lapplicable)
15.OUTER,CASING(for
` LINER C.C'
NC Well Contractor Certification Number FROM TO TINAiNiTHed " OR N S I MATERUL
McCall Brothers, Inc. 1 ft- 136 ft- 1 6.25 in. 0.28 Pvc
ConipanyNanic 16.INNER CASING,OR TUBING(geiithurnudduscit­loo))'.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:. 10012225 0 ft. ft. in.
List all applicable well construction permits(i.e.County,State,Variance.etc.) -
ft.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DLAMETFR SLOTSIZE THICKNESS MATERIAL
CAgricultural ElMunicipal/Public 0
0Gcothenual(14cating/Cooling Supply) OResidential Water Supply(single)
0 idustrial/Conimercial ❑OResidcritial Water Supply(shared) 18.IC;ROUT
FROM TO MATERIAL EMPLACEMENI'NIET[IOD&A,'*IOUN'I'
2rigation on
0 ft. 20 ft- B ent ps ite
800lbs pour from surface
chi
Non-Water Supply Well:
MMonitoring ORecoveq
Injection Well:
13Aquifer Recharge oGroundwater Remcdiation 19.SAND/GRAVEL PACK Of applicable).
[]Aquifer Storagc and Recovery 0Salinitv Barrier FROM TO _ MATERIAI EMENTNIFTIIOD
0
D Aquifer Test oStoninvaier Drainage ft.
DExperiniciltal Technology ElSubsidence Control
',20.DRILLING LOG(attach additional'stiects if necessary)
EIGcothernial(Closed Loop) []Tracer FROM TO DESCRIPTION(calnr,hardness,s(pillrock tviie,grain size,etc.)
[]Geothermal(Hearin Cooling Return) 0 011ier(explain under#21 Remarks) 0 26 ft. Red clay
4.Date Well(s)Completed: 3/17/2022 27 ft* so ft. Sandy clay
81 ft- 120 ft- Rocky clay
5.Well Location: 121 ft. 150 ft. Granite
Town of Matthews 150 ft- 200 I'll- Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1-1A
3024 Matthews mint hill rd, Matthews nc rt ft.
Pit 21.REMARKS,�
" ' -
Physical Address.City,and Zip A QP 9. T
Mecklenburg
County Parcel Identification No.(PIN)
.5h.Latitude and Longitude in degreolminutes/seconds or decimal degrees: 22.Certification:
(if welt field,one lat(long is sufficient) 3/18/2022
35007'57.8208" N 80040'59.556" W 4_)�
Signature of Certified Well Contractor Date
6.Is(are)the rmanent or ElTemporary well Bi,signing this fin-in,I hereby certify that the ivell(A was(mere)constructed in accordance
4W 1,;ith 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Coustractiva Standards and that a
7.Is this repair to an existing well: 0yes 00 No copy qf1his record has been provided it)the well owner.
ffthis is a repair,fill on known well construction iiijbi-nunion and explain the nature of the
repair under#21 remarks section or on rite back .f q thisforin. 23.Site diagram or additional well details:
You may use the back of this page to proNide additional well site details or well
8,Number of Wells CODAIIICMI: 1 constmcfion details. You may also attach additional pages if necessary.
For inaltiph,injection or nan-water supply iveltv ONLY with the same construction,you con�� submit one fora 24.Submittal Instructions:
9.Total well depth below land surface; 200 _(ft.) 24a. ForAll Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifilifferenz(araniple-3@200'and 2 @ 100') construction to the following: mation Processing Unit,
10.Static water level below top of casing: 20 _(ft.) Division of Water Quality,Info
level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter. above, also submit a copy of this form ivitWii 30 days of completion Of NN-011
12.Well construction method: Air rotary construction to the following:
(i.e,auger.rotary,cable,direct push.etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Centel-,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
Air lift 24c.For Water Suoolv&Geothermal Wells: Iii addition to sending the form to
13%Yield(gym) 15 Method of test: the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 12ounces - completion of ivell construction to'tNe county licalth department of the county
where constructed.
Fon11GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013