GW1-2021-00044_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wdl:ContritctorInformation:
Shane .Gossett M ,
FROM I TO DESCRIPTION
Well Contractor Name 140 ft- 141 ft. 75gpm
3528-A 185 ft- 186 ft. 225gpm
4
d; l
NC Well Contractor Certification Number tAl1 fi% 0 licaU +
FROM I TO DIAMETER THICKNESS I MATERIAL
McCall Brothers, Inc. 1 ft. 29 ft+ 6.25 in. 0.25 Pvc.
Company Nanre
FROM TO DIAMETER I THICKNESS I MATERIAL
2,Well Construction Permit#: N a 0 ft. ft.
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 I SIATS12E THICKNESS F MATERIAL
❑Agricultural ❑MmticipaliPublic In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑ dustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPIACEMENTMETROD @AMOUNT
tion 0 ft. 20 ft. Bentone pour from surface 750lbs
Non-Water Supply Well: ft. ft. chi s
❑Monitorntg ❑Recovery
Injection Well: ft. ft.
❑AgniferRccbarge ❑GroundwaterRemediation SniTTDI (Iic t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD0
❑Aquifer Test ❑StomlwaterDrainage
OEVerinictol Technology ❑Subsidence Control
r"1t;�R . ' O: nfl�h`radllltl l,al�fr�efs«If ants
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color bardness snntrock oTe,W*,tze,etc.
❑Geothemral(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 22 ft. Red clay
10/22/2021 23 ft, 30 ft, Granite
g.:Date.Well(s)Completed: 31 ft- 200 ft- Granite with quartz stringers
5.Well Location: 201 ft- 300 ft- Granite with quartz stringers
David Clark it,
Facility/Owner Name Facility M#(if applicable)
ft, ft.
Kidville rd Denver nc it, ft.
Physical Address.City,and Zip
Lincoln r1 —
County Parcel Identification No.(PIN) NOV V (� 021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one IaVlong is sufficient) DAIR SECTION
35029'32.244" N 81001'30.7812" W itTORMATIONINdef'991CUNi
Signature of Certified Well Contmctor Date
6.Is(are)the w rmanent or ❑Temporary By signing this form,I hereky certify that the rvelf(s)was(were)conimucted in,accordance
with 1 SA NCAC 02C.0700 or I5A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to on existing well: ❑Yes o•No copy of this record has been provided to the well owner.
if this'is a repain fill out known well construction information and eaplain the nature of the
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
A.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply.wells ONLY with the same construction,you con
24.Submittal Instructions:
submit one fann.
9.Total well depth below land surface. . 300_(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths ifelifferent(eanmple-3®200'and 2 @ 1001 construction t0 the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
If roarer level is above casing,use"+" lbl7 Mall Service Center,Raleigh,NC 276994617
11.Borehole diameter:
6 24b.For Injection Wells: In addition to sending the fort to the address in 24a
(in.)
above, also submit a copy of this form within 30 days of completion of•wcll
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,Ralcigb,NC 27699-1636
13a Yield(gpm) 300 Method of test: Air lift 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: Hth Amount: 20ounces completion of well construction to the county health department of the county
tY( where conducted.
form Gw-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013