GW1-2023-01856_Well Construction - GW1_20230222

I ,
WELL CONSTRUCTION RECORD orinternalUseONLY:
This form call be used for single or multiple%•ells
1.Well Contractor Information:
1`di;3VATER ZONES;?r?k ::. ri!;cs ` Id i+i =ir' -: {- 4:%
Shane Gossett FROM TO ` DESCRIPTION'!'
Well Collin.ctorNamc 400 - ft. 401 rh 2gpm
35 8-A• �;; ` r 523 ft. 523 ft. 29pm-:'
NC Well Contractor CcnilicationNumbcr assOUTERCASING foranulii ciiscaells OR:IiNEIt dri lie"u61c`:i k:i :'':'::;`t
FROM TO DIAMETER 1 1 THICKNESS MATERIAL
McCall Brothers, Inc. FEB 9 2, 2023 1 1 rt. 155 rt. 6.25 0.25 Steel
CompanyNmno Ini ;A+: ?; :y'.-:�.. i�l;i -.46:NNERCASIN.G'OR;TUBING;e6dJ'Friiial'chiscQtali'"
td• FROM TO DIAMETER THICKNESS ... MATERIAL
2.Well Construction Permit#: B 1704547 0i L5JG 0 rt, ft. 1n I.
Lfst all applicable well construction permlis(i.e.County,State.Variance,etc.) it. ft. in.
3.Well Use(check well use): 17.'SCREE .r?%'.? 'tr:, .h?'' .-'l):(s_:•; "t?*+'1?i}1 = 5=
Water Supply Well: FROM I TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑lytunicipaUPublic' ft. 0 ft. in. I ,
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
';18�GROU'L=r:r • iti^:a= s.i:--}iil1::;.!:.':ri• sy:ilpi�iit 3�5'�:;y}�it�''=iK`:`v"�: S�isS''� :Tj'.' .
binduslrial/Conuncrcial ❑Residendal Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD fi AMOUNT
01ni lion 0 ft. 25 ft, Benton te 1100lbs pour from surface
Non-Water Supply Well: chi s
ft. ft.
❑Monitoring ❑Recovery•
Injection Well:.• R: it.
❑AquifcrRecharge ❑GmundwalerRemcdialion FROM TO MATERIAL EtiPAG&'MAT'ERIAL ,.E,MPL.AC,FVIENT:-'METHOD
❑Agliifer Storage and Recovery ❑Salinity Barrier 0
❑Agmifer.Test ❑Stonmwater Drainage
ff. ft. '
❑Experimental Technology ❑Subsidence Control
:i20:.,DR[IiG1NCrIrOG nttacli:aide{ioiiuGsticeLsaLiiccessurv':•'C r:: t=i:.-='-' '2=:,
❑Geollict:Dal(Closed Loop) []Tracer FROM TO DESCRIPTION color.hanlnao.solUmck t) c.e 19*e.eta
❑Craolhctmal(Hcaling/Cooling Return) ❑Other(explain tinder 421 Remadcs) 1 0 u• 35 rt• Red clay
12�29�2022 36 ft- 100 ft' Saperlite
4.Date Wcll(s)Completed: 101 ft- 130 ft. Rocky clay _
5.Well Locations: 131' ft. 2-00 ft. Granite
Earnest estates r-.72i
1 rt• 400 rt• Granite
Facility/10imerNanto Facility iD#(ifapplicable)
=•ft. 700 ft. Granite;=.-:
1795 Sarah Dr Denver nc ft. ft.
Physical Address:City,and ZipEMA7tICS:;
Lincoln
County 'Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
:(if hell Geld,one Indlong is stCicimu)
3503(Y57.96" 2/2/2023
N 81°00'06.8436" �p
Signature of Ccntticd Well Contactor Date
6.Is(at r0)the wel�rmanenl or ❑Temporary By signing tlos form.I hereby certify that the mell(s)it-as(were)consinncted in accordance
•frith 15A NCAC 02C.0100 or ESA NCAC 02C.0200 Well Comstnictiotn Standards and that a
7.Is this a repair to an existing well: ❑Yes 00 No ropy of rhea record has been pmrided to the well corner.
Ijthis.is a repair,fill out known nrelf construction infonnatlon and etylain the nature of the
repair trader#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You stay use the back of this page to provide additional Well site delm'ls or well
B.Namb,r of wells constructed; 1 construction details. You may also attach additional pages if necessary.
ror multiple injection ortton-crater suppty wells ONLY trith the sane construction.you can
• smbiuir one form. 24.Submittal,Instructions:
9.Total well depth below land surface-. 700 (ft) 24;t For All Wells Submit this form within 30 days of completion of wall
Par nnuhiple arells list all depths(fdperent(eranple-3@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Quality,Information Processing Unit,
Ijttatet level is rrboi•c casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 24b.For Iniection Wells: In addition,to sending the form to the address in 24a
11.Borehole diamctcl•: (ins.) _
above, also submit a copy of this foal{within 30 days of completion of avell
12.Well cisnsfivction method: Air rotary I construction to the following:
(Lc.auger,rotary,cable,dimcl push,etc.) Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Centel,Rdeigh,NC 27699-1636
Air Ilft 21c.For Water Sunnly&Gemthcrmal Wells: In addition to sending the font to
13a.Yield.(glsm) 4 Methodof.test: the address(cs) above, also submit one dopy of this foml will 30 days of
20 ounces completion of well construction to the county health department of the county
13b.Disinfection type: Hth Amount: where constructed.
Form OW-I• � North Carolina Dcpanmcnl oCEncironmcnt and Natural Resources—Division of Water Quati I•
Revised]an.2013