GW1-2021-06842_Well Construction - GW1_20210419 (2)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ` �
Shane Gossett ,, . ' FRO14. M TO
Es DESCRIPTION
Well ContractorNanlc nup 1 9 400 ft. 401 ft- ? 17gpm
3528-A s 1- �r j[`e. `,)ijlt veils)TORNC Well Contractor Certification Numbcr l I1r3�1C(1 `t (Oj1 FROM15.
CASING for T!L1 TER LINER tf a`licablc
n r` �� f,
R THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 119 ft. 1 6.25 I ht. 0.25 pvc
Company Nano 16.INNER CASING OR TUBING(geothermal closed400 t
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 11779 0 ft. ft.
List all applicable well cmrstntction permits(i.e.County.State.Variance,etc.) ft. ft. _ in. -
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS17E THICKNESS MATERIAL
❑Agricultural ❑iviunicipal/Public p ft. ft. Io
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supple(single) ft. ft. in.
❑ dusuial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD R AMOUNT
i ation p ft. 119 ft. Portland trlmmie grout from bottom to
Non-Water Supply Well: oo_0
rt. , rt.
❑Monitoring ❑Rccovety
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK of applicable)
FROM TO MATERIAL EMPI..ACEMENTMETIIO
❑Aquifcr Storage and Recovery ❑Salinity Barrier 0 ft, ft.
❑Aquifcr Test ❑Slonrmvater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necescary
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,harinem,mil/rock Iv re, rain size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fl. 25 I'L red clay
26 ft, 80 it. sandy clay
4.Date Well(s)Completed:
3 18 2021
81 ft- 90 ft• loose saperlite
5.Well Location: 91 ft. 200 ft- granite
MSm 201 ft. 420 ft. granite with quartz stringers
Facility/Owner Name Facility ID#(if applicable) ft. ft.
813 Jefferson Dr Charlotte nc ft. ft.
Plnsical Address.Citv,and Zip 21.REMARKS`.
Mecklenburg
County Parcel identification No.(PIN)
Sir.Latitude and L.orgitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one taulong is sufficient)
35008'59.82" N 80047'05.604" W 4/1/2021
Signature of Certified Well Contractor Date
6.is(are)the we] rrnanent or ❑Temporary BY signing this fbnn,I hereby certify that the wells)was(mere)contsmtcted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction Standards auf that a
7.I5 this;1 repair to all existing well. ❑YCS o•No copy of this record has been provided to the well mener.
1f rhi.s is a repair,fill ma bictim well construction information and explain the nature of the
repair wider#21 rentarks section or at the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of e•ells constructed: 1 construction details. You may also attach additional pages if ncccssan.
F'or multiple injection or non-water supply wells ONLY with the same construction,you can
24.Submittal Instructions:one farot.
9.Total well depth below land surface: 420 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror nue4iple wells list all depths ifdifferent(trample-9ne 100'and 1CR/00') construction to(he following:
o Division of Water Quality,information.Processing Unit,
10.Static water level below top(if easing: �0 (rt.) 1617 Mail Service Center,Raleigh,NC 27699-1617
If tracer letel is above casing.use"+"
1 t.Borehole diameter:
6 24b.For injection Wells: In addition to sending the form to the address in 24a
(inJ
above, also subunit a copy of this form within 30 days of completion of w•cll
12.Well construction method: air rotary construction to lire following:
(i.e.auger,rotary,cable,dirccl push cic.)
Division of Water Quality,Uriilcrgr»und Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air lift 24c.For Water Sunnly&Geothermal Wells: In addition to sending lire form to
13a.Yield(gpm) 17 Method of test: the address(es) above, also submit one copy of this forni within 30 days of
hth Amount: 12ounces completion of well construction to the county health department of the county
13b.Disinfection type: Nvhcrc constructed.
FartuGW-1 Nonli Carolina Department of Environment and Nuturd Resources-Division of Watcr Quality Revised Jan.2013