GW1-2022-10827_Well Construction - GW1_20221209

WJPJLd.r l %JVA01J&U%-11V1`l 1%Z%1V1CU%%YW-11 internal use Only:
1."Welelll Contractor Information: -�- i,
(/1) 5 6,4///�rc�s_. JO yr' !�t �+/5 e / :14:tWATERZONES'', 'kz.i -:':i t: :4' ���t'.1::..,y,
Weil C- iiractorName FROM TO DFSCRinICH
,•,Q zi ) L4— A
NC Well CbnlractorCectiScalloaNumber i990UTER:t.ASING foFmulfi" wells OA'LINER fs"li�hle :;�: ..:?.„• -t•
vg`.`.
FR031 I TO DI AZIER 1 I TtnCHMS-:JnfATFdtlpl,
CompaoyName I L �/C.
�16:•INNER'CASINGORlTUBING: eotfieiwalelmed=lno �•s:'��:ii::sr^: 4�'t,r.•r.��'
2.Well Construction Permit#: /`]/yS'i(
FROM TO DWI:TER I I TfatCHNESS IhtATER1AL
Lfrt all applicable ivd(constnrctlon permits(Le.WC,County.State,Variance.eta) ft % ln.
I
3.Well Use(check well use): R• R• in•
Water Supply Well: yi7.'seREENia". ..'r; ;::k ?<S.x:fS"' 4 it'1i L v;?c u�s'f`.ti sly",�Ct i't}3•+
FROM I TO I DIMtEfER SLOTSC;E TH[C[4rFS5 MATERIAL
Agricultural I]Municipal/Public U ft
Geothermal(HeatinglCooling Supply) estdential Water Supply(single) & &
htd ' Commerci 31.
al DResidential Water Supply(shared) }�1ns..f�n ■Tn l
0.VJA�ull.rl.���t'J.•:I:S-�"1:1'G'.7fJ.'.��v4e:::•'r'nel:;'iti:•'ii"J'.e yeY+','1'v�8:.�'.�:Y}Ft:S a, •Y h ation FROM TO MATERIAL' EIHPLACEaniNTMETHOD&AMOUNT
Non-Water Supply Well: & r✓ e 0. Fri kJ
Monitoring Recovery ft iG
Injection Wen:
3. Aquifi:rRecbaMe E)GroundwaterRemediation
Aquifer Storage and Recovery r3SalinityBanier ?FROMND1G12AVEIiPAt:IC 'a''-lieabie�'•'Ii''.�ifci i%!:•:'i:. ��":;na1r.:-.;,�s;_;r}f+:�:1s,•
TO MATERIAL .£MpLACEM1rEt11TM6THOD••
_ AquiferTest 13StormwaterDminage tt
Experimental Technology OSubsidenceControl ft &
Geothermal(Closed Loop) 1311acer i20:DRILLINGLOG stfaeLsdditiSn'nlah6etiifiiec69a"
_ Geothermal(pleating/CoolingReturn) 110ther(explemunder-921Remarks) FROM To DESCRmzroN a ronbmdaemwnrmerc
f6 Jls—&
,
4.Date Wells)Completed:- �s'"q-2 Z/ Well ID# - ft* �- IL tJ n
Sa.Well Location: f( •-n• fe y o r1
-5.7//YJ w.e JT9"e r I)19`t1-D
F5m7Ity/OwnerName _ Facility IDll(tfapplicable) /j ft ]S-ft. R
1-7 4,4/rev e_ ft. ft. I'
PhysicalAddress.City.andZip ft
/�5�n 121:RFMA1tIGS:t�:.:r"•:ft�'��'t.�i?:a?sc:lilt .'.r.7,:;:i;rn�Y:-'3:`sr�:7±.'�6, :'ice:.::,:=-tr•:
County cr .Pamelydenti6cationNe.(P" G •� •i l 4-Le:
Sb.Latitude and longitude In degrees/minutes/seconds or dechnol degrees:
(ifwell field,one lat/iong is sufficient) 22.Certilieation: I'
S'D/5►t�r..�C/.7��e N I:2'�S` S`ff� W Unr
6IS(are)theweII(s)J Permanent or 07emporary Sis ofCessfi eltCootrsewr e
By sfgnfng thls form,I hereby eert/fy that th I rveli(s)was(vere)constructed in accordance
%Irsthisarepairtonnexistingwell: 13Yes or 131% withlSANCICOZC.OIOoorISR=COZC.0200iYellCow&ucitanStmdardsandthata
Jjddsisarepairfinautlmotvnwelieonstrucdonfiiformationanderplatnthenowreojthe eOPYOfthArecordhcsbeenpmvldedtothervellmmer.
repairunder#21 remarbseedon or on the backoflhisform.
23.Site diagram or addiflonpi well details:.
L For GeoprobdDPT or Closed-Loop Geothermal Welis having the same You may use the back of this page to piovide additional well site details or well
construction,only 1 GW--1 is needed. Indicate TOTALNUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled:
�•-•- SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface:_ 7iJ
Formaltlplewelfslfstalldepfheifdlfferent(exmrrple-3QZ00'andlaQl00� (ft) ��For All Welts; Submit this form within 30 days of completion of well
construction to the fol lowing:
10.Static water level below top of casing: (ft.) r• Division of Water Resources Information Processhig Unit,
Ijwaterlevdfs above earin&are'+" Iry7�g Se�ce cente�,Raldxb,NC27699.1617
il.Borehole diameter: 6 (in) 24b.For 7nteetion Welts: la addition to sending the form to the address in 24a
above,also submit one copy of this forin within 30 days
12.Well construction method:- n"�A�.r\I � of completioa'of well
(ie.auger.mtaw.eab*dfrectpusb.eta)- constructigato the following: i '
FOR WATER SUPPLY WELLS ONLY: Diylsitia of WaterResources,Underground following-
Injection ControlProgram,
1636 Mail Service Center,Raleigh,NC 27699=1636
13a.Yield m d I'
(Sp ) Method oftest: l 24a For Water Sunnly&Lniection Wells: In addition to sending the goon to
the address(es) above, also submit one6copy of this form within 30 days of
13b.Dlsinfeetion typeC k,,.'„e Antounh-3 2 i completion orwell construction to the county health department of the county
wheteconshucted.
FormGW-1 North C= naDepartmentofEnviroamtotalQuality-DivisionofWateritesaumes ,
• Revised2 22 2b16
t ,

D Work Order
Compar y Info Customer Servlic l Site
McCall Brothers Inc. STOWE MANOR 25665
PO Box 668710 217 S.CENTRALAVENUE 217 S CENTRALAVE
Charlotte-,NC 28266.8710 US BELMONT,NO 28012 US BELMONT,NO 28012 US
Phone:[phone] Contact: Contact:
Phone:[phone] Phone:
Fax: µ
Email:
xde'r� fu to e
^V 0 MW_"
.,JOB Description: NEW WATER WELL
Lead Techniciarr:
Requested By,JOE MCALPINE
Requested Date:1011712022
Rld, _• TEf, UL' Desc?ip AT
. .Tim _f! ater:'a'�*ih�Ciiw:t.,�rka� •.. ,ra.. r•d. fc• •r �a
Detail:
6°WATER WELL,EST 60'PVC,EST DEPTH 300',WANTS 25 GPM,GASTON CTY PERMIT#14058,SEE PERMIT FOR LOCATION,CALL 704-853.5200 FOR
GROUT INSPECTION,SEE PERMIT FOR WELL LOCATION,SEE ATTACHED MAP FOR DIRECTIONS
No work completed lines have been assoclated�with this rime and MaterialScope
36 �`L� �'� a �G // ScopeSubtohat �0.00 0.00 0.00 0.00'/0
IV
6
Work OrderTotat ;;0.00 0.00 0.00 0.00%
is
-7
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1 McCall Brothers Inc. Pagel I 10/17/22 08:48:21 AM
Date Format-MM/DD/YY SMWork0rder.rpt
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