GW1--04063_Well Construction - GW1_20230622

• WELL, CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
t4.-MATER.ZONEs V- •
Shane Gossett FROM TO DESCRIPTION
' Well Contractor Name 140 ft• 160 ft• 40gpm
3528-A rt. ft.
NC Well Contractor Certification Number 15:1)UTERCASING-(for niulti-easeil:wells)ORLiNER:(if.aji licahle)': . .
FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 116 ft. 6.25 in. 0.25 Steel
Company Name =16IlYNERCASING'ORITUBING(gcothcrmii4closed-looli)'r-'' , - . --. .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: 175937 0 ft. 122 ft. 4 in. 0.25 Pvc
List all applicable:well carstrm•tian permits(i.e.County.Slate.Variance.etc.) ft. ft. in.
3.Well Use(check well use): 17:SCREEN ':'.
Water Supply Well: FROM , TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
0 II' ft. in.
❑Agricultural -rJ unicipal/Public -
❑Geothemial(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. itt-
❑Industrial/Commercial :Residential Water Supply(shared) 18:_GROU C
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT •
❑Imgation 0 l•t• 20 rt. Bentonite Poured from surface
Non-Water Supply Well: _ chips
❑Monitoring ❑Recovery 0 ft• 122 ft. pramena Trlmmle grout
Injection Well: y ft. ft.
r .❑Aquifer Rechargy 4.T� i � tounda'ater Remediation 19.SAND/GRAVEL:PACK"(tf ajiplicable) - :
4r FROM TO MATERIAL EMPLACEMENT METttOD
❑Aquifer Storage a dltecovety n gSalinity Barrier 0 ft. ft.
❑Aquifer Test Jljl`, 9. �`'OStonnwaterDrainage
t ft. ft.
❑Experimental Technology ..,.. :isif9tasrdbeince Control
,'�n: f�' -20.DRILLINGLOG.(iutt ch atldiiiomiIshectsif necesitiri+). `:. " -
❑Geothermal(Cho .iro C0 ❑Tracer FROM TO DESCRIPTION(color,Pardee.%suitrock type,gram ma..etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under i12I Reniail:s) 0 ft• 30 It. Red clay
4.Date Well(s)Completed:
5 19 2023 31 ft. 90 ft. Sandy clay
-_
91 ft. 100 ft• Rocky clay
5.Well Location: 101 ft. 200 I. Granite
David novotny rt. ft.
Facility/Owner Name Facility IDi/or applicable) ft, ft.
8474 mono road catawba nc 28609 ft rt
Physical Address.City.and Zip "S.1bREMARICS>
Catawba Put a packer liner in to depth of 122'and trimmle grouted.
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one Iatilong is sufficient) /�
35°40'02.568" iy 80°58'14.358" W 4(As . 5/24/2023
•
Signature of Ccnificd Well Contractor Date
;,1• ,ra rntanent or ❑Tempora r 6.Is(are)the s1'el,. .By signing this form 1 hereby certify that the wells!was(were)constructed in accordance
r� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is tins a repair-to an existing Well: ❑Yes o•No copy of this record hac been provided to the well owner.
If this is a repair.fill out known well cmtsrxctioa information and explain the nnmre of the
repair under#21 remarks section or no the back of this firm. 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 wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water.supply wells ONLY with the stone construction,you can
submit late farm. 24.Submittal instructions:
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths ifdiQerent(example-.t@,200'and 2C'100') COnstniCtiou to the following:
10.Static water level below top of casing: 20 (I•t•) Division of Water Quality,Information Processing Unit,
if water level is above eosin*.use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the fonts 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 following:
(i,c.auger.rotary.cable,dimet push.etc.)
Division o1'Water Quality,Underground injection Control Program,
1 O WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Sunni).&Geothermal Wells: In addition to sending the fonts to
13a.Yield(gpns) . 40 Method of test: the address(es) above, also submit one copy of this form within 30 days of
131s.Disinfection ty se:_ Hth Amount: 20ounces completion of well construction to the county health department of the county
Iwhere constnucted.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised]an.2013