GW1-2022-10826_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For linernal Use ONLY.,
This form can be used for single or multiple wells
1.Well Contractor Information:
Shane Gossett FROM TO DESCRIPTION
WellConnactorName 120 -ft- 121 ft. ( I 25gpm
3528-A
, s 0UTEIRCAS2N ion frlficasfide115:7R W u
NC Well Conhactor Certification Number l LRi.][Wbe
FROM TD DIAMMR 1 THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 96 it. 6.25 1;in 0.25 Pvc.
a 1Iiv>licslri .t>atr)311,11 cuilTe"r"ai113clused9tio" , . :r
Company Name FROM TO DIAMETER I THICKNESS I MATERIAL.
2.Well Construction Permit#: 13 888 ft. ft. in•
List all applicable well casttuction pennits(i.e.County,State,Variance,etc.) ft. ft. �.
0 ,i
3.Well Use(check well use): < ?f
"Water Supply Well: FROM I TO DIAMETER •SLOTSI2E I THICKNESS I MATERIAL
120 ft. In.
❑Agricultural ❑ mumpal/Public
❑ mt GeotheaI eatin Cooli Supply) lesidential Water Supply(single) ft. ft. �•
p?ndustrfaltCommercial ❑Residential Water Supply(Shared)Shared 1;B.iGR014T �E .. _
'FROb! I TO MATERIAL EMPLACEMENT METHOD S AMOUNT
0 Hgadon 0 ft- 20 ft, en one Pour from surface 750lbs
Non-Water Supply Well: chips
tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation iW.-S Nb1G9AVS, UF2 C1{s ifta"'li atilt
FROM TO MATERLA7 I EMPLACEMENTTEWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 it. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Eapetimeutal Technology El Subsidence Control r
r20iDItIL+1'siNt �OGr attaGl�dIIItI0i1911AG*CCt9i1 VOWiaLl`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTIOx color,bardness soWroek size,Gte.
❑Geothemtal(Heating(Coolin Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. Red clay
26 ft. 50 ft. Saperllte
4.Date Well(s)Completed:
7/7/2022
51 rt. 80 ft. Rocky clay
5.Well Location: 81 ft. 100 ft. Granite
Shirley Cobb 101 ft. 200 ft- Granite
Facility/Owner Name Facility W#(1fapplicable) - tt. It.
333 chestnut ridge rd kings mountain ft.
Physical Address.City,and Zip r a f .,
Gaston
County Parcel Identification No.(PIN) —C V 9 2027
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: _ 'r•
(lfwcllfield,one lat/longissufficlen0 In,vr�r, ems. l ?l:C'v?u:: , Uric
35016'21.4896" N 81 'MrV�l�ti0G 7/20/2022
°20'11.5008 W
Sigmatuie of Certified Well Contactor Date
6.IS(are)the we"Wrmanent or ❑Temporary By'signing this fonn.I hereby certify that the well(s)was(were)constructed in accordance
with 13A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
No copy of this record has been provided to the well owner.
7.Is this a repair to-an existing well: ❑Yes -a•
if this is a repair,fill out known well construction information aid explain the nature of the
repair under#21 remarks section or on ilia back of this fornn. 23.Site diagram or additional well-details:
You may use the back of this page to,
.m 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-neater supply wells ONLY with the same construction,you can
submit one fonn. 24.Submittal Instructions:
9.Total well depth below land surface: 200 (ft) 24a. For All Wells: Submit this fonn,within 30 days of completion of well
For multiple wells list all depths if dl•Qerent(example-3@200'and 2 @100) construction to the following'.
10.Static water level below top of casing: 30 (ft.) Division of Water Quality;Information Processing Unit,
If tvatct level it above easing,use"+" 1617 Matz Service Centi rl Raleigh,NC 27699-1617
11.]Borehole diameter- 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well Construction method: Air rotary construction to the fotlowin
(i.e.auger,rotary,cable,direct pasln,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccnter,;Raldgh,NC 27699=1636
Air I lft 24c.For Water Stmaly&Geotherm f 1 Wells: In addition to sending the fomt to
13a.Yield(gpm) 25 Method of test: the address(es)above, also submit one copy of this form within 30 days of
Hth Amount: 20ounces completion of well construction to flue.county health department of the county
13b.Disinfection type: where constructed.
Revised Jan.2013
Form GW-1 Nottli Camlina Department of Environment and Natural Resources-Division of Water Quality