GW1-2021-07125_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD For hltemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERi7ANES
Shane Gossett FROM TO I DESCRIPTION
Well ContractorNamc 245 ft. 246 ft- I 309pm
3528-A
15:OUTER.CASING orlriuhi-cakt wels O L R •a llcsble
NCWc1lCmnmclorCenificmionNumbcr FROM TO. DIAMETER THICKNES MATERIAL
McCall Brothers, Inc. 1 ft. 79 ft. 6.25 in. 1 0.25 1 1 PVC
Company Namc 16.INNER.CASINGOR ING-1abeithdMall closed4tto
09-2020-13$137 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. tt. in:'
List all applicable well construction permits the.County.State.Variance,etc.)
3.Well Use(check well use): 17 SCREEN -
WaterSuppl'Well: FROM TO I DIAMETER I SLOTSiZE THICKNESS MATERIAL
❑AgricDllural D, unicipal/Pttblic',
0 ft. ft. in.
l7Gcolhennal(Hcating/Cooling Supply) Icsidential Water Supply(single) ft. ft. in.
Olndustrial/Coouncrcial OResidcntial Water Supply(shared) 18,GROUT :• `
FROM TO ~MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni Galion 0 ft. 22 fL chips
a Pour from surface 650lbs
Non-Water Supply Well: fl. R.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
OAquiferRccharge OGroundwatcrRemediation 119rUND/GRAYEL'PACK:rfa`litable
FROM TO I MATERIAL. EMPLACEMENT METHOD
❑Agtiifcr Stomgc and Recovery OSalinily Barrier 0 ft. ft.
❑Aquifer Test ❑Storunvater Drainage
rt. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGSAG aftai 1i;98ditioniil3bects'iGricccssary
❑Geolllennal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hourdnem soollbrock h7pe,p2in AM,Mal
OGcothenual(Heating/Cooling Return) OOlher(explain under#21 Remarks) 0 ft. 20 ft- Red clay
9 16 2021 21 ft. 70 IL Sapetilte
4.Date Well(s)Completed: 71 It. 100 fl- Granite
5.Well Location: 101 ft- 200 ft. Granite
Bluefield builder's 201 ft- 300 It. Granite
FacilityiOwnerNanrc Facility lDtr(ifapplicable) ft. ft.
2678 Trent pine cylinder Sherrill Ford nc 28637 rt. rt.
Plp•sical Address.City.and Zip 2l.REMARKS.„.
Catawba
County Parcel Identification No.(PIN)
1ti
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: tOOe'S,n
(if well field,one lat/long is sufficient) Ct
35037'13.5012" N 80056'18.4812" `,y 1tiIQCr'.3oi1p0
Signature of Cenificd Weil Contractor Date
6.Is(are)the wel rmanent or OTemporaty At,signing this Jana,I hereby cerrifv that the tvell(s)was(were)constructed in accordance
with I SA NCAC 02C.0J00 or 15A NCAC 02C.0200 Well Constntction Standards and that a
7.IS this a repair to an existing well: Oyes OeNo copy of this record has been provided to the well ourter.
/f this is a repair,fill out knonn well construction inforonanon and explain the nature of the
repair under#11 remarks seetion Or on the hack 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Few multiple injection(or non-n•ater supply wells ONLY frith the same construction.you can
submit One farm. 24.Submittal instructions:
9.Total well depth below land surface: 300 (ft) 24a..F'or All Wells: Submit this form within 30 days of completion of well
ror multiple wells list a0 depths if different(example-3@200'and 2Cn/00) 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 rasing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: Air rotary construction to the following:
(i.e.auger,ratan.cable,direct push etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air lift 24c.For Water Sunnhv&.Geotherm'al Wells: In addition to sending the font to
the address(es) above, also submit one copy of this form',within 30 days'of
131).Disinfection type: Mth Amount: 20ounces completion of yvcll construction to the county health department of the county
where constructed.
Fonn G W-1 North Carolina Department of Erwiromnent and Natural Resources-Division of Water Qttality Revised Jan.2013