GW1-2022-08474_Well Construction - GW1_20220427

1 .
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES'
Shane Gossett FR051 TO DESCRIPTION
Well Contractor Namc 140 ft. 141 ft. 50gpm
3528-A ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING(far multi-eased wells)OR LINER.if it ticable)
FROM TO DIAMETER TTIICKNESS MATERI IL
McCall Brothers,.Ihc. 1 ft. 96 It- 6.25 in. 0.28 Pvc
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
10012834 FROM TO DIAMETER TTIICKNESS MATERIAL
2.Well Construction Permit#: 1 ft. 107 ft. 4 in. 0.25 Pvc
PP
List all applicable well construction pennits(i.e.Cototn•,State,Variance,etc.)
• ft.
3.Well Use(check well use): 17.SCREEN
Water$upplyWell:, FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. ft. in.
❑Gcothcnnal(Hcating/Cooling Supply) ❑Residential Water Supply(single) ft. [t. in.
❑ dustrial/Conmicrcial ❑Residential Water Supply(shared) 18.GROUT'
FROM TO MATERIAL En1PLACEMENT HET110D R AMOUNT
alion 0 ft. 107 ft- Portlan Pour from surface 750lbs
Non-Water Supply Well:
Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑Groundwater Remcdiation 19.SANDIGRAVEL PACK tir applicable)
FROM TO MATERIAL EATPLACEMENTNIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑Stomnyatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
211.DRILLING LOG attach additional sheets if necessunv
❑Geolhen)tal(Closed Loop) []Tracer FROM TO DESCRIPTION(color,hanhim,miUrack type,Crain Are.etc.)
❑Gcothcnnal(Hcatin Cooling Return) ❑Other(explain under 1121 Remarks) 0 ft• 60 ft. Loose red dirt
61 ft, 80 ft. Rocky clay
4.Date Well(s)Completed: 81 ft. 100 ft. Granite
5.Well Location: 101 ft- 1 200 ft. Granite
Steven limentani ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ° :1 i_7 i�wl
801 Jefferson Dr Charlotte nc ft. n• PR .2 7
Plnsical Address.City,and Zip 21.REMARKS
Mecklenburg Has a Ilner to 10T ,,`:� mot,
County Parcel Identification No.(PIN) i;'; ^a"'� r` °'r 'wqY'• 1'�"1.Ji'l1V'L`�1 tJI V'.J�K-:�L iliilJ Yai.7l
ib.Latitude anli.Longitude in degrees/minutesAcconds or decimal degrees: 22.Certification:
(if ivell field,one la{/long is sufficient)
35009'00.3852" N 80047'03.966" W 4/14/2022
Signature of Cenificd Well Contractor Date
6.lis(are)the w'el4Wrmanent or ❑Temporary By signing this fonn.I hereby certify that(lie well(s)n•as(were.)constnicted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction Standards and that a
7.Is this a repair to an existing w'Cll: ❑Yes .0 No ropy of this record has been provided to the well on-ner.
lfthis is a repair,fill out know{hell construction information and explain the nature of the
repair wider#21 remarks section a•on the back of this form. 23.Site diagram or additional well details:
You play use the back of this page to proNide additional well site details or well
S.Number of Hells constructed: 1 construction details. You may also attach additional pages if necessary.
Far intdtiple injection or'non-water supply wells ONLY ivitli the saute construction,you Cain
submit one form. 24.Submittal instructions:
9..Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
For nwltiple n•ells list all depths i(dijjerew(exmnple-3@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy or this form within 30 days of completion of well
12.Well construction method: Air rotary construction to the following:
(i.e.auger,ratan',cable,direct push.etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of lest: Air lift 24c.For Water Sunnly&Geothermal Wells: in addition to sending the form to
the addrcss(cs) above, also submit one copy of this form within 30 days of
Hth Amount: 20ounces completion of well construction to the county health department of the county
13b.Disinfection hype: where constricted.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qnality Revised)an.2013