GW1-2021-07418_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14:WATER7.ONES
Shane Gossett \ FROM TO I DESCRIPTION
Well Contractor Name O�\ 240 It- 241 ft- 30gpm
3528-A o �,, ft.. ft.
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NC Well ContnclorCenificationNumber rg$S 1SOUTER CASING far multieasGllvclls OR LINER afi
iirsble r
\�
°' -` FROM TO. DIAMETER iCKNESS MATERIAL
McCall Brothers, Inc. \ ,a��RSt✓�`° 1 rut. 79 ft. 6.25 in- 0.25 Pvc
CompanyNnme 16INNEWCASINGOR'1[TB1NG. thermal;closetl4do
FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: EhW21-04186 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): 17.SCREEN.
Water Supply Well:
FROM J TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
[]Agricultural ❑ unicipal/Public
0 ft. ft. in.
❑Geothermal(Hcating/Cooling Supply) .4csidential Water Supply(single) ft• ft. ra
❑btdustrial/Commcncial []Residential.Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Nnigation 0 ft.. 22 ft. Bentonite Pour'from surface 800lbs
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery°
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rerediation 19.SAND/GRAVEL PACif if. "liable
FROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Storage and Recovery ❑Salinity Barrier 0
❑AquifcrTcst ❑Stonnw•aherDrainage N, ft.
❑Experimental Technology ❑Subsidence Control ZODRILII:ING`LOG rittecti addihoiiiilshcMs3fnecEsss
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness;sonfrock 13ye,gmin.wze,etc.)
❑Geothermal ftalingtCooliq Return) 00ther(explain under 421 Remarks) 0. N• 20 ft• Red clay
4.Date Well(s)Completed:
9 13 2021 21 ft* 70 ft. Saperilte
71 ft- 100 ft-' Granite
5.Well Location: 101 ft- 200 ft. Granite
Ken Blackburn 201 ft- 260 ft. Granite
Facility/0ssnor Name Facility 1D#(if applicable)
7074 executive circle Denver nc
Plwsical Address.City,and Zip 21.REMARKS,
Lincoln
County Parcel Identification No.(PiN)
56.Latitude and Longitude in degmec/minutes/seconds or decimal degrees: 22•Certification:
(if well field.one lat/loug is sufficient) n
35032'27.1572" N 81000'06.876" W pY�o./li 9/16/2021
Signature of Certified Well Contractor ! Date
6.Is(arc)the wel4wrmanent or ❑Temporar v
By signing this joro+,I!{ereM-rerrifv that the,vel!(s)++Y+s fwere)constructed in accordance
with 1 SA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and thm it
7.IS this a repair to an existing well: ❑Yes o•No ropy of this record has'been provided to rile well owner.
If this is a repair,fill out know)"•ell construction infornat+on and explain the nature of the
repair under N2l remarks sertion or on the hark of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details 6r.wc1l
8.Number of smells constructed: 1 construction details. You may also attach additional pages if necessary.
For nwhiple injection or rum-u•mer supply wells ONLY with the same tmtslruction-you can
24.Submittal Instructions:
submit one fim n.
9.Total well depth below land surface: 260 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmltiple wells fist all depths if eli-Qerem(example-3@200'and 2@ I00) 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 abort rasing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For iniection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this Form w�tliti 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,
L
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
ld(gpm) 30 Method of tcgt: Air lift 24c.For Water'Sunnly&Geothermal Wells: in addition to sending the form to
the address(es) above, also submitJone copy of this form within 30 days of
infection type: Hth Amount: 20ounces completion of well construction to lthe county health department of the county
where constructed.
North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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