GW1-2021-02484_Well Construction - GW1_20211118

WELL CONSTRUCTION RECORD For hftnW Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Shane Gossett ;1MF1RWM
so>a atascRa'rloN
WellCoutractorNamo 40 ft- 141 ft- 10gprn
3528-A n• rt.
NC.Well Contractor Certification Number
To DIADih9ER T®l3QtESS MA3ERiAL
McCall Brothers, Inc. 1 ft. 69 ft. In.
Company Name Mimi= mammon
13008 Fi= To D14?dF R Tluca UM MATERIAL.
2.Well Constriction Permit#: 0 ft. IL
List an applicable well construction permits(Le.Coun%'State.Variance,eta) ll. tt. In
3.Well Use(check well use):
Water Supply Well: -Rom To 014MEMm1lze
ft.
❑Agrieullural 24:dcnta,
cipl/Public 0 ft. in.
❑Geothermal(Healing/Cooling Supply) al Water
(Single) ft. ft. 1n
❑lndusttial/Commetcial ❑ResidentialWataSupply(sbared) FROM TO tv1A t EMP1A t►»3�t1D�QAM UNT
❑hri lion 0 tt• 25 tL chips e Pour from esurface 75016S
gon-wilter Supply well: Ft: tt.
I7Monitoring ❑Recovery
In pion ell:. ft. R.
❑Aquifer Recharge 0 Groundwater Romediation
ClAquifer Storage and Recovery 05alinity Barrier EOM I►u► UL tauel.A a aoD
p
❑Aquifer Test ❑Stonuvwer Drainage ft. .
❑EVetimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRJP•r ON e 1 jeflfmk a
❑Cmdumnal(Hearin fC h ntu a . Hard red clay
4.Date Well(s)Completed:
10/28/2021, 26 60 ft' Loose sand
61 fL 100 ft- Granite
5.Well Location: 101 ft- 200 ft- Granite with quartz stririgers
Betsey Remeriz ft. %
Facility/Owner Narne Facility ID#(if applicable)
201 shady 1.grove rd kings mountain.nc rt ft.
ft. n.
Ptrysrcal Address,City.and Zip
Gaston rVel
County Parcel Identification No.{PIN) DVVR SECTION
5b.Latitude And Longitude in degrees/minutWseconds or,decimal degrees: TION PROCESSING UNI1
(if tvelllield,one laf/long is smdlician[)
22.Certdieation:
WFOW35015'08.9352" N a31°17'24.162" W /�'�" " .11/9/2021
Sigr>ature of Certified Well Contractor Date
6.Is.(ace)the rmament Or ❑Temporary By egai„g dds form,I hereby certdy that the well(,)was(were)constructed In aciondatce
with 15A NCAC 02C-0100 or.15A NCAC 02C A200 Well Comwellon Standards and that a
7.Is this a repair to an.esisting well: ❑Yes O.NO copy ofthis record hat been,provided to the well owner,
!f this is a repah;fill out khown well construction information and explain the nature of the
repair under#21 remarks section or an the back of this ft,rm. 23:Site diagram or additional well details:
You may use the back of ft page to provide additional well Site details or well
8.Number of wells construeted: 1 cousuucdondetails. You may also atthchadditional}ages ifnecessary.
Formuldple h#ccilan or tom-water supply wells ONLYwith The same contraction,you can
submit one form. 24,Submittal Instructions:
9,Total well.depth below land surface: 200 (ft•) 24a, For An Wells: Submit this foam within 30 days of completion of.well
For multiple wells list all depths ifil(()erent•(example-3@200'and 20100) construction to the following:
10.Static water level below top Of casing: 30 (ft.) : Division of Water(Quality,l ormatiotl Proeming Unit,
((watcr level is above,easing,use"+" 1617 Mail ServiiecCeuter,Ralelgbi NC 2769'9-1617
11.Borehole diameter:. 6 (in.) 24b.For Injection Wells: ffi addition to sending the form to fly address in 24a
above, also submit a copy of this form within 36 days of oompletion of well
12.We0 000struction method: Alr rotary. constmdionto the.following:
(i o.auger,tummy,cable,direct pusl;etc.)
Division of Water Quality,Underground Injection Conti+ol Pnugrtim, .
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralelgh,NC 27699.1636
Airlift 24e.ForWatrr3muIV&GeotbetmaIVeih: In additionto sending the form to
13a.Yield'(gpm) 10 Method of test: _ the address(es)above, also submit one copy of this form within 30 days-of
13b.Di$infectiontype: Hth Amount 20ounces completion Of weD.constr0ction to the county health department of the couimty
where constmctA
FO.GW-I- North Carolina Dcpa*=tofBwimffiwnt and Natural ftwwces—Division ofWaterQvnitty Revised Jim 2013