GW1-2022-03715_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells'
1.Well Contractor Information:
14 + MA VARANNAt;.
Shane Gossett FROM To DESCRIPTION
Welt ContractoiNnnic 280 ft. 281 ft- 20gpm
3528-A'
340 ft, 342 'fL 5gpm
NC Well Cotdmctor Certification Number f6•UYlt7i o ul', .
FROM TO DIAMETER THICKNESS MATERIAL
.McCall Brothers, Inc. 1 ft. 157 ft. 6,25 in. 0.25 PVC
Company Name 4 . B q
FROM TO DIAMETER THICKNESS MATERIAL
is Well Construction Permit#: 22-008 0
List all applicable.well construction permits(Le.Coumy,State,Variance,etc.) ft., ft. in.
3.Well Use.(checkwell use): SOS( F Y
Water Supply Well: FROM ' TO DIAMETER SLOTSM THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic 0 ft: ft. in..
.❑Geothermal eatin Cooli Supply) OResidential Water Supply tt., ft in
(FJ g/ ng uPP Y) PP Y
❑ dustdaUCommercial ❑Residential Water Supply(shared) $
FROM TO MATERIAL EMPWCEMENTMETROD& UNT
ation 0 ft- 20 ft- Bentone Pour'from surface 1100lbs
chi s
Non-Water Supply.Well: rt. ft.
❑Monitoring (]Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19. A!!lD! t11C it tKl
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM MATERIAL RMPLACEM0rrMETHOD0
i
❑Aquifer Test ❑Storrnwater Drainage
❑Experimetrtal Technology ❑Subsidence Control s 2p in I1'O _ ailUtlt dl bile fie
❑Gcothemral(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardnen seillrock fm grain 1bbN Mc.):.
1:1 deotherriml Oieatingtqooling Return) ❑Other(explain under#21 Rernarks)I 0 ft, 26 ft. Red clay
4..Date Well Completed:
3 4 2022 27 ft, 80 ft. silt clay
81 ft. 140 it. Weathered rock
5.Well Location:
141 ft- 200 ft- Granite ,
Eric brubaker 201 ft. I�360 ft. 4�'�E�G Fanite-� l'
Facility/Owner Narne Facility ID#(if applicable)
ft. ft.
804 medallion dr waxhaw nc ft. n. MAR 3 0 202?
Physical Address,City,and Zip
Union 06174492
County Parcel Identification No.(PIN)
I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.'Certification:
(if well field,one lat/long is sufficient)
35001'11.1648" N 80046'48.6948" A 3/16/2022
Signature of Certified Well Contractor Date
6.Is(are)the w rmanent or ❑Temporary By signing this Jam,I hereby certb ilia the well(s)was(were)constructed in'accotzlance
n nth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 00NO n spy of this record has been provided to the well mmer.
If this is a repair,full out known well construction information and explain the nature of the
repair under#21 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 wetl
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessaty.
For mulliple igfection or non-water supply wells ONLY with the scone construction,you can
submit one form. 24.Submittal.Instructions:
9,Total well depth below land surface: 360 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor tnuttiple wells list all depths if different(example-3@200'and 2@ 100) construction to idle following:
10.Static water level below top of casing: 20 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Boreho le diameter: 6 On.) tab.For Injection Wells: In addition to sending the foam to the address in 24a
above, also submit a copy of this forum within 30 days of completion of well
12.Well.constluestion 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 Centel•,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of tent: Air Ilft 24c.For Water Supply&Geothe al•Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfectionitipe: Hth Amount: 20ounces NAltere constructed,
Form GW-1 Notch Carolina Department of Erwironmeat and D alural Resources—Division of Water(uWlity- Revised Jan.,2013