GW1-2021-06992_Well Construction - GW1_20210507

WELL CONSTRUCTION RECORD For Lmmal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett R CEIVED
.FROM TO DESCRIPTION
Well Contractor Name 245 ft- 246 ft. 5gpm
�,4p,Y X 7 2021 260 ft. 261 ft- 15gpm
3.528-A ,
10
NC Well ContmctorCertificationNu er �jlllt ' aY26411' x`Itli[lElt;iC%a
Information Process►ng FROM To DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. DWR Section 1 ft. 172 ft. 6.25 in. 0.25 steel
Company Name hTCt [1B tc1d9ZIt
FROM TO DIAMETER TAICIOPESS MATERIAL
2.Well Construction Permft#: EH2O-00707 0 ft. ft. in.
List all.applicable well construction permits(i.e.County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTS1ZIi TIiIc[class MATERLtI
0 ft. ft. in.
❑Agricultural ❑ umcipal/Public
OGeothemral eatin Cooli Supply) residential Water Su (single) ft. ft. in.
(H b/ nS tePp Y) PP1Y(� g
Olndustrial/Commercial oResidential Water Supply(shared) ROGRE111;
FROM TO ARTERIAL EINPLACEMENTMETROD.@AMODf'IT
Olrri 9tion 0 ft
22 ft. en one chips pour from surface 700lbs
Non-Water Supply Well:
OMonitoring oRecovery I
Injection Well:
❑Aquifer Recharge OGroundwaterRemediation I z-0 lc c
FRO O M TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinily Barrier 0
OAquiferTest ❑StormwaterDrainage ft tt.
[I Experimental Technology ❑Subsidence Control t)DRIr31lt b g e jgiiil a l$ti 'ti
OGeothemtal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,lurdnan inlIk uck etc
OGcothermal(Heatin Cooli Return ❑Other(explain under#21 Remarks) 0 ft. 25 ft- red clay
26 ft. 80 it. loose sandy clay
4.Date Well Completed: 4/14/2021 81 ft. 160 ft, tight clay
5.Well Location: 161 ft- 200 ft- granite
earnest estates 201 It- 300 ft, granite with quartz'stringers
Facility/Owner Nante Facility ID#(if applicable) ft. ft.
7659 Sarah Dr Denver nc it, ft,
physical Address.City,and Zip 0Z1dRE11I t8TCS -
Lincoln
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
gyp. 4/16/2021
35030'56.6064" N 80059'43.6164" W
Signature of Certified Well Contractor Date
6.Is(are)the wet�rmanent or OTemporary By signing this fan.I hereby certify that the well(s)was(were)constructed in accordance
width 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an esisfing well: ❑Yes o•No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the 23.Site di am or additional well details'
repair tinder#2.1 remarks section or on the back of this form. 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 sntppiy wells ONLY with the same construction,you can
24.Submittal instructions:
submit one form.
9,Total well depth below land surface. 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion Of well
For multiple wells list all depths if different(example-310200•and 2®.100) Construction to the following:
10.Static water level below top of casing: 35 (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+"
16.17 Matz Service Center,Raleigh,NC 276994617
6 24b.For Injection Wells: In addition to sending the form to the address in 24a
11.13orehole diameter: Cn•) above, also submit a copy of this;form within 30 days of completion of well
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 Center,Raleigh,NC 27699-1636
13,FOR WATER SUPPLY WELLS ONLY:
air lift 24c.For Water ..U I &Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 20_ Method of test: the address(es)above, also submit one copy of this form within 30 days of
20ounces completion of well construction td the county health department of the county
13b.Disinfection type: hth Amount where constructed.
Revised Jan.2013
Form GW-I North Cam Una Departmentof Environment and Natural
Resources-Division of Water Quality