GW1-2022-10737_Well Construction - GW1_20221208

i
WELL CONSTRUCTION RECORD .
For Internal Use ONLY: �
This form can be used for single or multiple ivells
1,Well Contractor Information:
Shane Gossett FROM I TO DESCRIPTION
We11 Contractor Name 221 ft. 222 ft. 5gpm
3528-A 345 ft 346 ft. 5gpm
iSJOVXERCASINGf `rAniiltl asc'di"ivallB 10RtI3vIl WMai`"icabl'c
NC Well Contactor Ccttification Number FROM TO DIAMETER THICKNESS. MATERIAL
McCall Brothers, Inc. 1 ft. 209 ft. 6.25 in. 0.25 Steel
Company Name �dILTNEI[;GASINGa0l14CUBTf!tGt7 cutGcmal cluscitL7uo t r % a f
FROM TO I DIAMETER I THICKNESS MATERIAL
2.WellConstructionPermit#: EhW21-05583 0 ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): W175GREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUrI
0 ft. ft in
❑Agricultural ❑ unicmpal/Public
[]Geothermal(Heating/Cooling Supply) Iesidential Water Supply(single) ft. ft. in
' -1tt�GRO�,U3'�z� "�c��;�.?x� ,:•. .",, a�,-+�? �%
❑hidustrial/Commercial ❑Residential Water Supply(shared) FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
oHgadon 0 It. 20 ft. en one 900lbs
Non-Water supply well: chips
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Renmaliation ?0,SAND%G7tr•.ftF,ltltAGKKk ta'PP
°'"lirhtll'c" alzr ' �'..zt
FROM TO MATMLr1. I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑StoriwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ,,w • 3
n0:DYtTtiMNG11rtT6:attaaliiadilitl�ntiltslieets"df:riccessacv
[]Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,bardnes%solltrock -min&6,etc.
Cl Geothermal(Heating(Cooli Return) ❑Other(ex lam underW21 Remarks) 0 ft, 30 ft. Red clay
022 31 ft. 180 ft. Grey Rocky sandy clay
11 21
4,Date Well(s)Completed: /2 181 ft. 185 it. Loose rock
5.Well Location: 186 ft- 210 ft, Granite
Earnest estates 211 ft. 360 ft- Granite
FacilitylOmvnerName Facility ID#(if applicable) ft. ft.
7675 Sarah Dr Denver nc
Physical Address,City,and Zip tu]t1TtEtVIARKSa?ti2 ` �aaa .1a.` �� xle's► #c
Lincoln' 91677•
PatcelldentificationNo.(PIN)
County —
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:' 22,Certification: Un,I
lny,v r1 r•.rii`�1
(if well field,one latflong is sufficient) �s f,•'�f;�
Q�350516058 N 8009958548 W 11/23/2022
�/"Y,
Signature of Certified Well Contractor Date
6.Is(are)thew rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 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 copy of this record has been provided to the well mvner.
if this is a repair,fill out known well construction Information and explain the nature of the
repair tinder#21 remarkv 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 nmhiple injection or non-water supply wells ONLY with the same construction,you can
24,Submittal Instructions:
submit one fona
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@.100) construction to the.following:
10.Static water level below top of casing: 40 00 Division of Water Quality,Information Processing Unit,
/f water level hs above casing.use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
6 24b.For Iniection Wells: In addition to sending the form to the address In 24a
11.Borehole diameter: (in.)
above, also submit a copy of this foram within 30 days of completion of well
12.Well construction method:
Air rotary construction to time following:
(i.e.auger,rotary,cable,ditect push,etc.) Division of Water Quality,Underground Nection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c For Water Sunnly R.6cothe al Wells: In addition to sending the form to
10 Method of test
13a,Yield(gpm) the addresses)above, also submit one copy of this form within 30 days of
Hth Amount. 20ounces completion of well construction to rile county health department of the county
13b.Disinfection type: where constructed.
Fonn GW-1 North Carolina Department of Environment and NatumlResources-Division of Water Q i uality RcAsed Jan,2013