GW1--04148_Well Construction - GW1_20230623

• A r CONSTRUCTION RECORD For Internal Use ONLY:
' . .....,,.m he used for single or multiple wells
1.Well Contractor Information:
14;:WATER:ZONES - •
Shane Gossett FROM TO DESCRIPTION I
Well Contractor Name 140 ft. 141. ft. 1 i 7gpm
153 fly 154 It. • 13gpm
3528-a .5.OUTERWCASING(fticinulti,cased.Wells)ORLINER(if ap licahle)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 90 ft. 6.25 in. 0.25 Pvc
Company Name 16.1NNER CASINGOR TUBING=(eedthetniaLelosed.loop): ..
FROM TO DIAMETER THICKNESS MATERIAL i
Z.Well Construction Permit#:
Ehw21-05713 0 ft• ft. in.
List all applicable well construction permits(i.e..County,Slate.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17..SGREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: FROM
II' ft.
t❑Agticulturl ❑lylunicipa1IPublic
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) • _
18.GROUT.•
l❑Indnstnalonlriercial ❑Residential Water Supply(shared) FROM 'ro MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irritation 0 ft. 20 ft. Be ebonite Poured from surface 800Ibs
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery
ft. ft.
Injection Well •
❑Aquifer Recharge • ❑Groundwater Remediation .19.SAND/GRAVEL:PACK0f:aimpticable):._= ' - •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery Salinity Barrier 0 ft. • ft. ,
❑AquiferTest ❑Storm•aterDrainage ft. ft.
❑Czpetinmenlal Technology ❑Subsidence Control ;20::DRILLINGLOC(at!ICItudditionalsheets,ifnecessarP)• '_:
❑,,,eoilsemml(Closed Loop) OTracer FROM TO DESCRIPTION(calor,rrantnccr,sail/rock type,grain size.etc.)
❑Geothermal(Healing/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 26 ft. Red clay
27 ft. 50 ft. Saperlite
4.Date Well(s)Completed: 4/27/2023 51 ft. 80 ft. Rocky clay
5:Well Location: 81 ft. 100 ft. Granite j
fl. ft. Granite l
Mario vie• 101 160 1
Facility/Owner Name Facility IDfi(if applicable) 161 ft. 200 ft. Granite i
4041 Bordeaux-Dr Denver nc H. ft.
Physical Address.City.and Zip a''-t" "•'" r}r`"'i
Lincoln •
County Parcel identification No.(PIN) JUN�+ 1 U13
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1 r CC •�s/.+•. f) .
(if well field.one tat/long is sufficient) . . SS•ltviillaa� ' p r•
QQ�� /1 Dlc0'3`3 5/4/2023
35°31'52.4028" N 81°00'07.1028" W h
Signautn:of Ccnificd Well Contractor Date
6.Is(are)the weIrmanent or ❑Temporary By.signing this Jim,I hereby certi\ That the wells)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Co smtctian Standards and that a
7.Is this a repair to an existing well: ❑Yes o®No ropy of this record has been provided to the well owner.
If this is ft repair,fill out kno'to well construction intimation and explain the nature of do 23.Site diagram or additional well details:
repair under N21 reanrks Medan or MI the back Otitis form.
You may use the back of this page to provide additional well site details or well
11.Number of wells constructed: 1 constriction details. You may also attach additional pages if necessary.
Far n:ultipfr injection or nor-water supply wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form. :
200 tt 24a. For All Wells: Submit this form within 30 days of completion of well
F Total well depth 11b eft'land surface:(e 2 (ft)
) constriction to the following:
For multiple tacdls fist off depths i(diQerwu trample-aC'200'hurl_@ 100')
1
Division of Water Quality,Information Processing Unit,
If r ter level
water lei el casing,
use
top of casing: 25 (tt.) •
1617 Mail Service Center,Raleigh,NC 2 769 9-1 6 1 7
If water lrrcl is above cn.cing,nsr.,.+'.
6 24b.For iniection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: (in.) above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
. Air rotary • constriction to the following:
tic.auger.ratan•,cable,direct push.etc.) Division of Water Quality,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I 13.FOR WATER SUPPLY WELLS ONLY:
20ounces Air lift 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a Yield(gpm) 20 Method of test:_ the address(es) above. also submit one copy of this form within 30 days of
• completion of well construction to the county health department of the county
13b.Disintcction'type: Hth Amount: -- where constructed.
Form GW-I - North Carolina Dcpanntent of Em•iroumcut and Natural Resources-Division of Water Quality
Revised Jan.2013