GW1-2023-02835_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.,Well Contractor Information;
Shane Gossett FROM I TO DESCRIPTION
WellContrnctorNante 450 ft- 51 ft. 40gpm
ft. ft.
'3528-A
_.._..tY1111i1"1 �1 f6i�5n""r71 ,' �•1 10R�'II;16 ffa Il@till "
NC Well Contractor Certification Number FROM TO I DIAMETER TE[ICRTiESS MATERIAL
McCall Brothers, Inc. 1 ft. 41 ft.. in.
.Company Name � ')uq;S�, :el�l'ivYC�IOR �iG " ' 'e• sett�.lan - � �i
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#/: 22-318 0 ft. ft. in,
List all applicable well coustruction permits(i.e.Count),,State,Variance,etc.) In.
ft. ft.
3.Well Use(ebeckwell use): 7 57312E1i = .
Water supply well: FROM TO , DIAMETER SLOTSIZE TLIIC[tNI SS MATERIAL
❑Agrictiltural ❑MunicipaVPublic
0 ft. et. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fa M.
MET
gTlmdustriaVCotnmercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT nOD AMOUNT
R
Irri ation 0 ft. 20 I't.
Non-Water Supply Well: ft. ft.
❑Monitorhtg ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GmundwaterRemediation
FROM TO MATERIAL EMPLACF,MENT METI[OD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑StonnwaterDrainagc
❑Exile inmental Technology ❑Subsidence Control
. . . . . ismrt81
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness swumek rym pain, etc.
❑Geothermal(Heatin Coolie Return) ❑Other(explain under Remarks) 0 ft. 25 ft. Red clay
9 16 2022 26 ft- 30 ft. Rocky clay
4.DateWell(s)Completed: 31 ft, 50 ft. Granite
S.Well Location: 51 ft. 200 ft- Granite
Arcadia_-homes- 201 ft' 460 ft. Granite
Facility/OwnerNatrie FacilityM#(if applicable) ft. ft.
503 ancient oak-lane wdxhaw nc
Physical Address,City,and Zip nr
Union
Courtly Parcel Identification No.(PIN) ArR G I.LJ
5b.Latitude and Longitude in de tro/minutes/seconds ondecimal degrees: 22.Certit cation: {rmi�irGi:;,4�•;l
.;_....,;:._•-.. .') ,�,,.,
(if well field,one laVloag is sufficient)
4 io/s/zozz
35001'19.344" N 80047'40.50.6" W
Signature of Certified Well Contractor Date
G.Is(are)the we rmanent or ❑Temporary By signing this farm,1 hereby certify that the wells)was(were)constnrcted in accordance
tuirb 15A NCAC 02C.0700 or 15A NCAC 02C.0200 Nell Construction Standards mud that a
7.Is this a repair,to an existing well: []Yes OeNo copy of this record has been provided to the well mvner.
if this is a repair,fill out known well cousintetion information and mplain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or cos the back of this form. gt
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.
ro•multiple ityectimr or nou-svoer supply yells ONLY with the same construction,you can 24.Submittal Instructions:submit one form:
9.Total well depth bclow.land surface:
460 (ft.)
24a. For AiI Wellsc Submit tins form Within 30 days of completion of well
Far multiple wells list all depths if ili ferenr(exmnple-3 Q200"and 2 @ 700) construction to the following.
Division of Water•Quality,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
If water level is above casing,use"+"
6 24b.For Injection Wells: In addition to sending the form to the address in 24,
11.Borehole diameter: (m.) above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
Air rotary construction to the f0110wh1g:
(i.e.anger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Neetion Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
Air lift 24t^ ly&GeoWermal Wells: In addition to sending the form to
13a.Yield(gpm) 40 Method of test: the address(cs)above, also submit one copy of this form within 30 days of
20ounces completion of well construction 1:6 time county healllt depattment Of the county
13b.Disinfection type:Hth Amo
unt;mount; where.constructed.
North Carolina Department of Environment and Natural Resources—Division of Water t2uality
Revised Jan.2013