GW1--04149_Well Construction - GW1_20230623

' WELL CONSTRUCTION RECORD Forinterntil Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
la:WATERZONES1-: -
Shane Gossett FROM TO DESCRIPTION
Well Contractor Name 160 it 161 rt. lOgpm
3528a ft. ft.
NC Well Contractor Certification Number =15:OUTERCASING,(forsiiulti.casei:wdfs)-OR.LINER:(ifhp lientile)
FROM TO DIAMETER THICKNESS �'MATERIAL
McCall Brothers, Inc. 1 ft! 79 ft. 6 in. 0.25 Pvc
Company Nunn 16:INNER-CASING ORTUBING=(gcothMuial-closcd=loon)
30498 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 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): 19;SCREEN:''
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 ft. ft. in.
❑Agticultuml ❑ unicipal/Public
❑Geothermal(HeatingiCooling Supply) `Residential Water Supply(single) ft. ft. in.
❑Industrial/Conunercial ❑Residential Water Supply(shared) .18:;GROUT ;. '' - - - --. . , _.. - . .-
FROM17 TO` MATERIAL _ EMPLACEMENT METHOD&AMOUNT
❑Trrigalion 0 it• 22 ft. Bentonite Poured from surface 800lbs
chips
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation -19.SAND/GRAVEL PACK(ifapplicable),• -- .
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test 0 Stonmvater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
-'20:'DRILLINGLOG(attach;ndditinual'sheets-ifnccess:inv)-, .; - . -
❑Geothemtal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnew.snit/rock type.main size,Cie.)
❑Geothermal(licaling/CoolingReturn) ❑other(explain under 421 Remarks) 0 ft. 25 ft. Red clay
4.Date Well(s)Completed:
4 28 2023 26 ft. 70 ft. Rocky clay
71 ft• 100 ft. Granite
5.Well Location: 101 rt. 200 ft• Granite
Tyler carpenter ft. ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft. 7-- ty U
801 lenders chapel rd lincolnton nc ft ft �„•,f L....
Physical Address.City.and Zip 2.1:=REMARKS . _':.- _-: '= . t� 9 •°!'':10 3 ' -
Lincoln J�,I!
County Parcel identification No.(PiN) t.n.f:'rc r:j "�
5b.Latitude and.Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one Ial/long is sufficient) AIL
35°24'33.4224" N 81°16'42.888" w ��1�-1 •- 5/18/2023
Signature of Certified Well Contractor Date
6.Is(arc)the weleltnnanent or ❑Temporary Br.sliming this form,I hereby cur*,that tire wells)was(were)comsnvcted in accordance
with/5A NCI C 02C.0100 or iSA NCAC 02C.0200 1Ve1!Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the tie!!mrncr.
if this is a repair.fIll out known well comma-rim informations and explain the stature of the
repair under#21 remarks section or on the back of this form. 23.Site(flagrant 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 constmction details. You may also attach additional pages if necessary.
For multiple injection or nrut-tinter supply wells ONLY with the Sane construction,you can
.snWnit one form. 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
Far multiple wells list all depths if different 1e:ram/sle-5@200'and 2ne 100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
ljlr•ater•level is(shore easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fonts within 30 days of completion of well
12.Well construction method Air rotary constmction to the following:
li,e.auger,rotary.cable.direct posh.etc.)
Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air lift 24c.For Water Smutty&Geothermal Wells: In addition to sending the form to
the address(es) above. also submit one copy of this fonts within 30 days of
13b.Disinfection type: Hth Amount: 12ounces completion of well construction tot the county health department of the county
where constructed.
Fonts GW-I North Carolina Depanarom of Euwironmcnt and Natural Resources-Division of Water Quality Revised Jan.2013