GW1-2021-00430_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett FROM TO DESCRIPTION
WeltContractorName 165 fL 166 ft- 5gpm,
3528-A 285 ft. 286 ft- 3gpm
NC Well Contractor Certification Number 5 e h
FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, inc. 1 ft. 54 ft- 6.25 in. 0.25 Pvc
' Company Name
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: EhW21-05988 o ft. ft. ln.
List all applicable wellconstruction pennits(i.e.Counry.Stare,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ld�l'S s1EE
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THtcRN.ESS MATERIAL
❑Agricultural umcipal/Public
o f. ft. in.
❑Geothermal(Heatin JCooling Supply) esidential Water Supply h(single) f. ft. in.
❑Industrial/Commercial ❑ResidentiaI Water Supply(shared) FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri lion 0 ft. 22 [L en one chips
Pour from surface 750lbs
-NowWa(cr SupplyWell:, ------- ft. ft,
❑Monitoring ❑Recovery
action Welii --
dAquifcrRecharge ❑GroundwaterRemediation FROM To MATERIAL r-h: AND/fs"• t�Klc .. . •r:.
EMPLACEMENT METHOD
0 Aquifer Storage and Recovery. ❑Salinity Barrier 0 . ft, ,
❑Aquifer Test ❑StomtwaterDrainage
❑P_xperinieantal Technology ❑Subsidence Control gtrylpgn'# >silfrs`siii% j
❑{xcotitennal(Closed Loop) OTracer FROM I TO DESCRIPTION color,hartinect xWr1xk etc.
aCeeothertnal-(HcatiD Cooli Return ❑other(explain under#21 Rernanks) 0" ft. 26 ft. Red clay
10/29/2021 27 rt. 45 ft. Rocky clay
4..Date Wells)Completed: 46 ft- 100 ft. Granite
5.Well Location: 101 ft- 200 ft- Granite
Keystone builder's 201 ft. 340 ft. Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft. a�/
5823 'Old plank rd"iron station nc 28080 ft, ft.
Physical Address.City.and Zip
Lincoln
County Parcel Identification No.(PIN) IN
5b.Latitude and Longitude in d es/minutes/seconds or decimal d t VfJI
g► egre egress: 22.�CertificatioW
(if'well frold,one tat/long is sufficient.).
35026'41.1" N 81003'23.2572" by . ti•/!a/zoo
i
Signature of Certified Well Contractor Date
.6..Is(are)the W rmanent . or ❑Temporary By signing this farm.I.hereby certify that the wells)was(were)Constructed in'accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.lis this a repair to an tAgdng"well: ❑Yes 00NO copy of this record has heart provided to the well owner.
'if tttis is c'r&pair,fill tntr known well construction information and eaylain the naive of the
repair tireei•J/2.1 remarks section or on the back of rlds farm. 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 wells wnstrvcted:. construction details. You may also attach additional pages if necessary.
Poe multiple injection or non-water:apply wells ONLY with the saute construction,you can
ewtirnit one form: 24.Submittal instructions:
9.Total:wcll depth.below land surface: 340 0t.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple walls.nst all depths iydt ferent(example-3@200'and 2 @ 1001 construction t0 the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit,
If water/eye!is above,Casing.-use."+" 1617 Mail Service Ce4 ter,Raleigh,NC 27699-1617
it.Borehole diameter: 6 (in.) 24b.For Injection 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.Weil.construction method:
Air.rotary . construction to the following:
(i.e.anger,..rotary,cable,direci push,etc.) Division of Water Quality,Underground Injection Control Program,
LFFORWATER SUPPLYWELLS ONLY: 1636 Mail Service Cen�ter,Raleigh,NC 27699-1636
Methodoftest: Air lift 24c.For Water Sunniv&Geothermai Wells: In additiar to sending the form to
the address(es)above, also submit!one copy of this form within 30 days of
Hth Amount: 20ouncescompletion of well construction to the county health department of the county
nfection type:_ where constructed. .
Porm GW-i
Nort hCaro)ina Department of Enviionment and Natural Resources—Division of Water Qtmli(Y Revised Jan.2013