GW1-2022-10738_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For lutemal Use ONLY: i
;his•four can be used for•singlc or multiple wells
L,Well Contractor Information. k
ShaneGossett mom To DEsciamox'I
We].Contracwr:Name 245 tL 246 ft. P 7gpm
286 ft• 287 ft- 33gpm
•3528-A
NC Well Contractor Certification Number FROM TO DIAMETER THiCrC MS MATERLIL -
McCall Brothers,.Inc. 1 ft. 202 ft. 6.25 1i1. 0.25 Steel
Coppany Name
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#t EhS21-02126 ft, ft.
List all aTilicable well construction pcnnits(i.e.County State,Variance,etc.) 0 ft. ft
3,,Well Use(check welt use):
Water Stipply Well: FROM To DIAMETER MMSIZE TMCKNFSS MATERUL
❑Agricultural C3 trt»cipaVFublic p in.
ft. ft.
bacothemtal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Contmercial ❑Residential Water Supply(shared)
FROM TO I MATZML EMPLACEMlINTMl3THOD R AMOITNI' .
❑hri •tlion 0 ft. 20 ft- Ben on a 9001bs
Pion-Water Supply Well: ft. ft, chi s
0Monitoring ❑Recovery
Injection Well: ft. ft.
MAqulferRecharge' 130roundwaterRemediation e
FROM TO MATERIAL fiMI'LACF.MEN r METHOD
pAquifer Storage and Recovery ❑Salinity Barrier fL ft,
❑Aquifer Test ❑Stontwater Drainage
0
❑Expeaiutental Technology ❑Subsidence Control
od&s isdifu :: .;
❑Geotlternlal'(Closed Loop) ❑Tracer FROM TO DESCRIPTION color bardow soltrockt n etc
❑Geotheunal(Heatin Colin .Retum) ❑0ther(explain under#21Rema8rs) 0 ft. 50 ft. Red clay
4.Date Wgll(s)Completed:
11/1/2022 51 ft- 160 ft- saperiite
161 ft. 180 ft. Rocky clay
5.Well Location
101 ft' 250 ft. Granite
Earnest estates 251 ft, 320 ft- Granite
Facility/4wn6r Nance Faeiiitq MO(if applicable)
Sarah Dr:Dr:Denver, nc
Physical Addwss;"City and Zip r �� i _
w
� r
Lincoln 91676 v
county Paticel Identification No.(PIN) "
•_ 1 tr*•'s'
5b.Latitude and Longitude in de es/mimrtes/seconds or decimal degrees:
•(ifiyellGold,anolalllougts�sufficiont) � � 22•Certiflcation:
35051534280 N 800996531 Rt 11/23/2022
Signatuto of Certified Well Contractor Date
6.43(are)the rmanent. or ❑Temporary By signing rids fonn,1 hereby certify that the well(s)was(were)constructed in accordance
'with ISA NCAC 02C.0700 or 15A NCAC 02C.0200 Well Construction Standards and that a
7,Is thus a repair to-ail existing well: ❑'Yes 4WO copy of this record has been provided to the well owner.
if this is a r epah;fill onrknown well construction information and explain the nature of the
repair under#21 remarks section or on the back of this 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 6f wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the soma construction,you can
sub6t one forma ' 24.Submittal instructions:
9.Total:well depth below land surface: 320 (ft.) 24a.For All Wells: Submit this fonn within 30 days of completion of well
For nurtripie wells list all depths(f dWerent(example-3@200'and 2 @100) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Quality,1 rmattion Processing Unit,
!f water!es el is above eaair:g;use"t" 1617 Matt Service Centel,l2aleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Welis: In addition Ito sending the form to the address in 24a
above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: Air rotary construction to the fallowing:
(La.auger,rotary,cable(Ureotpuslt,eta) Division of Water Quality,Underground Injection Control Program,
1636 Mall Service Center,Weigh,NC 27699-1436
13,.FOR WATER SUPPLYWELLS ONLY- t
13a.Yield.(gpm) 40 Method of test: Air lift 24e.For Water Smmhv&GEothermab Wells: In addition to sending the fonn to
the address(es)above, also submit one copy of this'form within 30 days of
33b.Disinfection lath lath Amount* 20ounces completion of well construction to thef county health department of the county
�p where constructed,
i
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Form MAF l•- Nortb Carolina Department of Emdroument and Natural Resources-Division ofWatcr lZuality Revised Jan.2013
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