GW1-2022-09991_Well Construction - GW1_20221104

WELT CONSTRUCTION RECORD Fm latMnl Use ONLY:
�flus(am=be mad for single or multiple wells
1.Well Contractor Information:
Shane Gossett PROM TO eta of —,
Wellcom eamNlarm 120 R• 1 121 „• lOgpm
352d-A 135 n• 1 136 It. I 20gpm
NC Well Contractor Certification Muslim INYaw To I DIAatnv 1 71mcmxm 1 MaamAL
MC2VI Brothers, Inc. 1 R 95 f 1 5.25 hL.1 0.25 1 Galvanlzed steel
Company kam:
13841 PROM To RLWRTER T�(101pH MATOUL
2.W'dl Construction Permit a: 0 ft, ft. in.
Lin all°r1plksb/e uw0 carutrumlon pe..am(Le Corny,Sulu.Panaac4 de.) ft. ft. IL
3.Well Uae(check well use):
Water Supply Well: mold I To I DIAMInFER I SLOTsird
❑Agriculbaral ❑I/�mucipal/Public h. ft. Jr.
❑Geothermal(HeatinglCootir.g Supply) l .,dential Water Supply(single) n. t, In
01ndustafal/commercial ❑Residential Water Supply(shared) PROM Tb MATERIAL EMPLACLMWITM67R END a
R LN
❑1ni n 0 R• 20 ft• ch°5 a 7001bs
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery, _
Injection Well: ID ft•
❑Aquder Recharge ❑CaouodwaterRemediatlon
MATERIAL DeLACEMMMEt'ROD
OAquifey Storage and Raavery OSeliniry Border 0 R h
❑,Teat ❑Stomrwater Drainage R 0.
❑Experiancri Technology ❑Subsidence Control
❑GeotieQnal(Closed Loop) ❑Tracer PROM To b eoR/mxk eta
❑Geothermal (Heating/Cooling Rehm Clothier(explain utder#21 Remarks) 0 8• 10 0• Red clay
4.Date Tell($)Completed; 7/15/2022 11 IL 30 n' Saperlite
31 0• 80 IIL Rocky clay
S.Well location:
81 6 100 IL Granite
.Mark deaton 101 R' 140. IL Soft brown rock
Fwft/O*iw Nam Facilin mg(if applicable) 141 IL 200 % Soft brown rock
329 chestnut ridge rd kings mountain nc OL aL
PhysiW Addicts.City,and Zip
11 Gaston
County Pawed identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: t
(((well field.one I nnoug is sm0ciem) p
x� � (JITd
3 °16'21.198" /iNrr4-' in+'d0' 7/26/2022
�` N 81°20'12.0984" K, ifns� rwctiaoGi
— SigmtneofCertiaelwancorlmcim DMw
6.Is(are)the q anent or ❑Tmnponwy BY s/gsdag ads form.1 hereby Mrs*that the xs0(s)was(were)coanruded to accordance
whh ISA NCAC 02C.0100 or 15A NCAC 02C MW Well Construction Standard,and that a
7.Is this a repair to an existing well: ❑YU 00No copy ofthu rcmrd has been provided to the well owner.
/f th4 is a repadr,fill oul knoum well coamruenan information and explain the nature of the
repab muter#21 remanlr section or on the back ofthkrform 23.Site diagram or additional well details:
Yon may,use the back of this page in provide additional well site details or well
S.Nation*of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multlpk Wenelon or nw,-iwter supply wells ONLY x4A ds omit construction.you can
sabmh ontform. - 24.Submittal Instructions:
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30-days of completion of well
Formrhipll weflr Hsl all depths ifd�erenr lrsnmp/e-3®200'ard 2®/W7 construction to the following:
10.Static,water level below top of casing. 20 (ft.) Division of Water Quality,Information Processing Unit,
!f x "le wd h above casing,um.+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Rajah,diameter. 6 (La.) 24b.For Injection Wells: In aMinan to sending floe 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:_ __ construction to the following:
(La:auger,dreary,cable direct peak do Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.mill(gp r)- 30. - .Method etalsk Air IIR 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the addfeu(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: •lith Assonant 12ounees completion of well construction to the county health department of tie courdy
where cot�sWeLed.