GW1-2021-02532_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple mvells
1.Well Contractor Information:
Shane Gossett .
FROM I TO DESCRIPTION
Well Contractor Name b� tn� 225 ft- 226 ft• lOgpm
3528-A 235 ft. 236 ft. 30gpm
Iv�AY 2 n_ illi< i all
NC Well Contractor Certification Number
Q��,SA,I� OM TO DIAMETER TKICKNESS MATERIAL
McCall Brothers, Inc. icg3;l; cn�� 1 rt. 192 ft- 6.25 gin• 0.25 steel
•^ '- FROM TO DIAMETER .
Company Name vv,
Ehw21-01033 THICKNESS MATERIAL2.Well Construction Permit M. 0 fit. ft. in•
List all applicable well construction permits(Le.County,State,Variance,etc.) ft. ft. in.3.Well Use(cheek well use): ft.vN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipaUPublic 0 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lesidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri Lion 0 fit. 20 tt. en on e
chips pour from surface 700lbs
Non-Water Supply Well: IL ft.
❑Monitoring ❑Recovery
Injection Well: rt. tt.
❑Aquifer Recharge ❑GroundwaterRemediation Az- : Il
FROM I TO MATERTAi. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
rt. n.
❑Experimental Technology ❑Subsidence Control
MAWaldlkonl free
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnen w,iUrack tM grain tMc
❑Geothermal(Hcatin Coolir Retum) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. red clay
4.Date Well(s)Completed:
4 29 2021 26 ft, 180 ft. saperlite
181 ft- 200 ft- granite
5.Well Location: 201 It- 240 ft. granite
earnest estates ft. ft.
Facility/Owner Name Facility 1D#(if applicable)
it, rt.
7681 Katherine Dr Denver nc ft. n.
Physical Address,City,and Zip
Lincoln
County Porcel Idemification No.(PIN)
5b.Latitude and Longitude in degmeshninutes/seconds or decimal degrees: 22,Cer'ttFcatiou:
(if well Geld,one lat/long is sufficient)
35e31'0.04" N 80059'40.152" Rt / 5/13/2021
Signature of Certified Well Contractor Date
6.I,S(are)thewelqWrmanent or ❑Temporary By signing rids form,I hereby certify that4he well(s)was(were)constructed in accordance
with 15A NCAC 02C.0700 or 15A NCAC 62C.0200 Wen Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 00NO copy of this record has been provided to the well owner.
If this is a repair,fill out knorvrt well construction information and explain the nature of the
repair tmderd2l remarks section or on 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 nudtiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 240 24a. For AN Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{(different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,lnformation Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cenitet',Raleigh,NC 276994617
11.Borehole diameter: 6 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this forth 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 11�ethod of test: air lift 24c.For Water Sunnly&Geotherttial Wells:. In additi ti to sending the form to
the address(es)above, also submit one copy of this,form within 30 days of
13b.Disinfection e: hth Amount: 20ounces completion of well construction to the county health department of the county
type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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