GW1-2021-07361_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple sells
1.Well Contractor Information: •
K WATER ZONES
Shane Gossett �� FROM TO I DESCRIPTION
Well Connactor Name 341 ft. .342 fL 40gpm
3528-A �1
NC Well ContmctorCetiificalion Number OUR TEC�ING fof.:mulotiAMs flcUs ORLDVER' a 1icebie
FR R - THICKNESS MATERIAL .:.
McCall Brothers, Inc. �i���` Secs' 1 ft. 12 ft. 6.25 !n. 0.25 pvc
Company Name ham; a 16.INNER.CAS G:OR:TUBING: ."thernfid elOE W406 =G-
Ehw2104187 FROM TO DIAMETER THICKNESS MATERIAL
-
2.Well Construction Permit#: p ft. ft.
List all applicable"ell constntction permits(i.e.County.State.Variance,etc.) ft. ft, in.
3.Well Use(check well use): 17.SCREEN. ..
Water Supply Well: FROM TO I DIAMETER I SLOTstZE I THICKNESS I
..MATERIAL
❑AgriculWral ❑ utucipal/Pttblic 0 ft. rt. In.
❑Geothermal(Heating/Cooling Supply) 4esidential Water Supply(single) ft. ft. in.
❑industrial/Conuncrcial i7Residential Water Supply(shared) 18:.GROUT. :.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni Lion 0 it. 28 ft. Bentonite Pour from surface 700lbs
Non-Water Supply Well:
ONIoniloring ❑Recovery
Injection Well: ft; ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAYEL:PACK'd': licible
❑Aquifer Storage and Recovery ❑Salinity Bamer FROM TO I MATERIAL I EMPLACEMENT:METHOD
. ft.
❑AquiferTcst OStonmvaterDrainage 0 ft
ft. ft.
OExperirrlcnial Technology ❑Subsidence Control
20.DRILLING G auto'ch:'sildiKonel:sbcctsifatxess
❑Geothemtal(Closed Loop) OTracei FROM TO DESCRIPTION cobr,hardness,saNrockt in ' ate
OGeolhemtal(Hcatin Coolin Return) ❑Other(ex lain under#21 Remarks) 0 ft. 20 ft. Red clay
4.Date Well(s)Completed:
9 8 2021 21 ft- 118 ft. Saperllte
119 ft. 200 ft. Granite
S.Well Location: 201 ft- 360 ft. Granite
Ken Blackbum
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7054 executive circle Denver nc
Plwsical Address.City,and Zip 21.REMARKS`
Lincoln
County• Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:.
(if well field.one ladlong is sufficient)
35032'27.3948" N 81000'09.7596" W 9/16/2021
Signature of Certified Well Commoor ' Dale
6.Is(are)the wel�rmanent or ❑Temporan- By signing this faun,I hereby cerlif thnithe well(s)ors(room)constructed in accordance
midi 15A NCAC 01C.0100 or ISA NCAG02C.0200 Well Construction Standards and that a
7.is this a repair t0 all existing well: OYes o•No copy of this record has been provided to die well owner. .
If this it a repair,fill out knotsm it-ell consinrction infornration and explain the nature of lite
repair tender N21 remarks section or(in 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For uwhiple injection or non-water supply wells ONLY with the saint construction,you can
subunit one fitnu: 24.Submittal Instructions:
9.Total well depth below land surface: 360 (ft.) 24a, For All Wells: Submit this form within 30'days of completion of well
Fnr multiple n•ells lit all depths if different(example-3C 200'and 2 n 100) construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Qualih•,Information Processing Unit,
If water level is above erasing,use••+ 1617 Mail Service Ccnter,Raleigh,NC 276994617
11.Borcholc 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 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,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: Air lift 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
the address(es) above. also submit one copy,of thus form within 30 days of
° 13b.Disinfection tyiie: Hth Amount:. 20ounces completion of well construction to the county' health department of the county
where constructed.
rorr=GW-I North Carolina Department of Environment and Nammt Resources-Division of Water Qnatity Revised tan.2013