GW1-2022-10830_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
i4,�1'YAITERiLONEBu�`•'�t..`Kr �� i .� ",� :`.:.���°��' � �>,
Shane Gossett FROM TO DESCRIMON
WellCoattactorName 140 ft. 141 ft. 20gpm
3528-A 1so ft. 151 ft. I 20gprn
NC Well Contractor Certification Muriber Y15 OU1EXCASING$ ulirrasce113sOxi} IOTTERt>F"aiibI0) r x 3 Via;
FROM TO DIAMETER I THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 115 it. 6.25 1 in. 0.25 Pvc
Company Name T6 IPIbIEYt'C LSTNG ORuEt3Bik F ebiheriuiNc dseit47au
FROM TO DIAMETER TrICKNESS MATERIAL
2.Well Construction Permit#: 13887 0 ft. ft. In.
List all applicable well construction permits(Le.County,State,Variance,etc.) ft. ft. ;' In.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICRNFMS MATERIAL
❑Agricultural ❑ tuucmpaUPr Supply(single)ublic
1 It- 120 ft- in.
❑Geothermal(Heating/Cooling Supply) residential Wate ft. ft. In.
:is'zt>ItOUT.Txaa _ iL
❑hulustriallCommergial ❑Residenha]Water Supply(shared) FROM TO MATERIAL FNTI ACEMENT N ETHOD&AMOUNT
❑Irri Lion 0 ft. 20 ft. en on a pour from surface 750lbs
Non-Water Supply Well: chips
ft. 2 ft-
❑Monitoring ❑Recovery
Imaiection Well:
❑Aquifer Recharge ❑GroundwaterRemediation aL�Si1TTD7 1t ELd~i1CK rfra Gca>i c K _ �
❑A mmifer Storage and Recovery ❑Salim Barrier. FROM TO MATERIAL EMPLACEMENT METHOD
q g r ty o : ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control20ts1)12II:ti1�f4G,Afta"tsfuadiUtConn1s" If<nccam° "
❑Geothermal(Closed Loop) ❑Tracer FROM• TO DESCRIPTION color barduen snalmck eta
❑Geothermal(Hcatin Coolin Return) ❑Other(explain under 421 Remarks) 0 ft• 25 ft• Red clay
26 ft. 80 ft' sandy clay
4.Date Well(s)Completed:
7/11/2022
81 ft. 100 ft. Rocky clay
5.Well Location: 101 ft- 150 ft- Granite
Debbie Murray 151 ft- 200 ft. Quartz and mika
Facilitylowner Name Facility IN(if applicable) ft. ft.
335 chestnut ridge rd kings mountain nc n.
Physical Address,City,and Zip ,`N.1FA—E-TARKS_R ', x a
Gaston `C
County Parcel IdentiricationNo.(PIN)
5b.Latitude and Longitude in degiveshninuteslseconds or decimal degrees: 22.Cerffication:
(if welt field,one latnong is safficleta) t 7/20/2022
35016'22.4724" N 81020'11.4648" W I'n1
Signature of Certified Well Contractor Date
6.Is(are)thewegWrmanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes o•No copy of this record has been provided to the,ivell mvrter.
If this Is a repair,fill out known well construction b:formation and explain the nature of the
repair under#27 remarks section or on the back of this fora. 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 webs constructed: 1 consfmction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can.
submit one fonnn. 24.Submittal Instructions:
9.Total well depth below land surface: 200 (ft) 24a. For All Wells: Submit this foil within 30 days of completion of well
For multiple wells list all depths if ili erenr(example-3@200'and 2 @.100) construction to the
following—Division of Water Qualityl Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,iltaleigh,NC 27699-1617
13.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 eottstruction method: Air rotary construction to the following: i
(Le.auger,rotary,cable,direct push,eta) Division of Water Quality,Undei ground in jeetion Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centcr,,Ralcigb,NC 27699-1636
I
40 Method of test: Air lift 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) the address(es)above, also submit one copy of this form within 30 days of
Hth Anoint: 20ounces completion of well construction to the county health department of the county
13b.Disinfection type: where constructed. }I
Revised Tan.2013
Fenn GN-1
North Corolima Department of Environment and NammIResources-Division of WaterQualiry