GW1--04069_Well Construction - GW1_20230622

WELL CONSTRUCTION RECORD I For intertxd Use ONLY:
This font:can be used for single or multiple wells
I.Weil Contractor Information:
Shane Gossett • FROM
AfERZONES DESCRIPTION
Weil Contractor Name 140 ft. 141 ft. 2gpm
3528-A
289 ft- 290 ft• 59Pm
NC Well Cenuactor Certification Number 15:'OUTER CASING(for;nrulh Gi'setkrells)'OR;LINEW(if apphcable);._'=
FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 39 ft. 6.25 in. 0.25 Pvc
Company Name 16.INNER-CASING;OffiTUBING(geothermuhctosed loop) -.-i; ,. _ --
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 14043 0 ft. ft. in.
List all applicable well construction permits(i.e.County.State_Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17:SCREEN- ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 ft, ft. in,
❑Agricultural ❑ unicipaUPublic -
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. hi.
❑Industrial/Commercial ❑Residential Water Supply(shared) -1tt:.GROUT: ... _...
FROM TO MATERIAL EMPLACEMENT METHOD h AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well:
OMonitoring ❑Recovery 0 ft. 22 ft• Bentonite chips Poured from surface 1200lbs
Injection Well: ft. ft.
'❑Aquifer Recharge • ❑Groundwater Remediation 19..SAND/GRAVEL:PACK-Waiiplicahtc) _ - .. --
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 • ft. ft.
❑Aquifer Test DStonmvalerDrainage ft. ft.
❑)xperimental Technology ❑Subsidence Control
0.DRILLING`•LOG.(attachadditionalsliectanecesaari)':, '
0Geothe:*real(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hariItten soil/rock type,grate,size,etc.)
.OGeolheninal(Heating/Cooling Return) ❑Outer(explain under 421 Remarks) 0 ft. 13 ft. Red clay
d.-bate Well(s)Completed:
3/9 2023 la ft' 25 ft. Saperlite
•
. 26 ft. 30 ft. Sorry rock
5.Well Location:
31 ft. 40 ft. Granite
David Witherspoon 41 rt. 100 ft. Granite
Facility/Owner Name Facility iD!!(if applicable)
101 it• 300 ft. Granite
.546 stockwood marks church rd Bessemer city nc II. ft• . r-�
y
Physical Address.City.and Zip 77 *v�.t"„�
;;21:RE141ARKS -: _ .. ,
' • Cleveland • QIlN 9 9 70
County ParcelIdentificationNo.(PIN) + - `�`�
9b,Latitude and Longitude in degreesfminntes/seconds or decimal degrees: ltti'C.ro ;t�sl PrC.; rsQ•,f;g Urfa
22.Certification:
. (if well field,one lalilong is sufficient) CA14.0130(.1
35°21.'22.68" N 81°20'11.3244" W / 5/11/2023
Signature of Certified Well Conuactor Date
. 6.is(are)the welekennanent or OTemporaty By signing this loon,I hereby certify that the well(sl was(were)cmtstntcted in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes 0®N° copy gfthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may.use the back of this page to provide additional well site details or well
8.Ntutrl:•:r of wells constructed: 1 constmction details. You may also attach additional pages if necessary.
Far multiple injection or nnn•watrr supply wells ONLY with the saute construction,you can
submit are form. 24.Submittal inshvctions:
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple sells list all depths,fdifferent(example-$@200'and 2@/00') constriction to the following:
10.Stalk water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,nae"f.' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ 6 _(in.) 241). For Injection 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 following:
(i.e.auger,rotary,cubic,direct push,etc)
Division of Water Quality,Underground injection Control Program,
j 13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7- Method of test: .Alr lift 24c.For Water Sootily&Geothermal Wells: In addition to sending the form to
the address(es) above. also submit one copy of this-form within 30 days of
I Hth Amount: 12ounces completion of well construction to'the county health department of the county
113b.Disinfection type: — where constructed.
Fort GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013