GW1-2022-08494_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD For Internal Use oNLY:
This form can be used for single or,multiple wells
i
1.Well Contractorinfortnation:
14.WATER ZONES
Shane'Gossett FROM TO DESCRIPTION
Wc1LContmciorNanic 122 ft- 123 ft. 40gom
3528-A
ft. ft.
•
NC Well Contntctor Certification Number 15.OUTER CASING for multi cased n eli)OR LINER if a livable
FROM TO DIAMETER i THICK ESS MATERIAL
McCall Brothers,Inc. 1 ft. 1 46 ft- 1 6.25 in• 0:25 PVC
Company Nanic 16.INNER CASING OR TUBING cothermal closed400
FROM TO DiAMETER TRICKINESS MATERLIL
1Q012768 1 49 4 0.25 Pvc.
2.Well Construction Permit#: tt: ft: in.
List all applicable well co»siniction permits(i.e.Courtly,`State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Suppy Well: FRO51 TO DIAMETER I SLOT SIZE• THICKNESS I MATERIAL
❑Agriculluml ❑Municipal/Public 0 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑ FR
Industrial/Contmercial ❑Residential Water Supply(shared) GROUT '
. FROM I 70 MATERIAL EMPrACEMENT METHOD&AMOUNT
❑lni ation 0 ft. 20 ft- Bentonite Pour 750lbs
Non-Water Supply Well:
❑Monitoring ❑Recovery 0 n• 49 it: Ptirtlandc Pour from surface
Injection Well:
❑AquiferRccharge ❑Groundwater Remediation, 19.SAND/GRAVEL PACK(if applicable)
❑ F '
Aquifer Storage and Recovery ❑Salinity Barrier ROM TO MATERIAL Fh.1PLACEMENTMETHOD
0
❑AquifcrTest ❑StonmsaterDminage ft. ft.❑Experimental Tcclmology ❑Subsidence Control
20.DRILLING LOG attach additional sbLets if n arc
❑Geotilemtal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(coldr,hardnm%soill6citt e,graintiroetc)
❑Geothemial.(Hcating/Cooling Return) ❑Other(explain under#21 Reniadcs) 0 ft. 8 ft. Red clay
3 22 2�22 9 tt. '4U ft' 1Eoose�rO k^-
4.Date Well(s)Completed: .41 ft; 100 it• Granite
5.Well Location:
101 ft. 200 ft. Q�
Pester usa ft, ft.
Facility/O ncrName Facility ID#(ifapplicable)
13534 Reese Blvd Huntersville nc " ,,�• •x`se: ll`'
ft: ft Vi 0it 1;U..ii d`i`i' 1� 'T
PIiysical Address.Cip•,and Zip 21.REMARKS
Mecklenburg Well as for In Packer liner from-1 ft to 49 ft
County Parcel Identification No.(PiN) I i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
3/31/2022
35023'30.8796" N 80051'34.0884" �,y '
Sigmture of Certified Well Contractor Date
6.Is(are)the welellermanent or ❑Temporan' By signbig this forni,I hereby certify that the irell(s)it-as(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Co struction.Standards and that a
7.Is this a repair to an existing well: Dyes .o•No copy ofthis record has been provided to the 4,11 owner. '
If this is a repair,fill out known well construction infonnanon and erpkiin rite nature of the
repair ander#2/remarks section or on the b6ck of this form• 23.Site diagram or,additional ivell details:
You may use the back of this page to provide additional well site details or,,well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.,
For multiple injection or non-water supply wells ONLY with rile same construction,yott coil
stibmit onefornt 24.Submittal Instructions:
9.Total swell depth below land surface: 200 (ft.) 24a. For All Wells: Submit this-form within 30 days-of completion of well
Far ninhiple wells list all depths ifiti ferew(erample-3@200'and 2@100) construction t0 the follotiing-
10.Static water level below top of casing: 20 (ft,) Division of Water Quality,Information Processing Unit, „
Ifsrarer lerel is abuiv casing,ase"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition,to sending the-form to the address in 24a
above, also submit a copy of this form within 39 days of completion of well
12.Well construction method: Air rotary construction to the following:
(i.e.auger,rotary,cable direct push era.) Division of Water Quality,Underground Ipketion Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Methodof test: Air lift 24c.For Water Sunnh•&Geothermal Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
]3b.Disinfection hype: Hth Amount: 20ounces completion of well construction to the�,county heolth department of,the county
where constructed.
Form GW-I i North Carolina Department of Emirenment°and Natural Resources-Dhision of Watcr Quality Revised Jan 2013