GW1--04210_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
-;l4sWATER�ZONES • ,
Shane Gossett FROM TO DESCRIPTION
Well Contractor Nance 143 ft• 144 ft. I 20gpm
3528-A 166 ft• 167 ft. 20gpm
NC Well Contractor Certification Number .•15.OUTER=CASING.(fnr multi-eiisedAvells)ARtiUVER?(if-itp'licable). : .. _.
FROM TO - DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft• 102 ft. 6.25 in. 0.25 Pvc
Company Name `16:1INNERCASING:ORTUBING(gcotberirial closed-loop)•:,- -
13871 FROM TO DIAMETER THICKNESS MATERIAL
IWell Construction Permit N: 0 it. ft. in.
List all applicable well construction permits(i.e.County.Slate.Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural ❑lylunicipal/Public 0 ft, ft. in.
•
❑Geotlhermal(Heating/Cooling Supply) Residential Water Supply(single) fl, ft. in,
•
❑Industrial/Commercial ❑Residential Water Supply(shared) ..GROUT -• - ," ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 80 ft. Bentonite Poured from surface 12501bs
Non-Water Supply Well: chips
❑Monitoring ❑Recovery It• It•
IIIjectioa Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation =t9 SAND/GRAV,ELPACIC(If apjdicable)'-=-,..; ?- '.'•.
FROM _ TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and ReCOVery ❑Salinity Barrier 0 ft. ft.
❑Aquifer Test ❑Stomm'a ter Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
-.20.DRILLiNGLOG-(attach'additionalshenlsif:necessary)._,.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Kolar,hanhtccs,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 35 ft• Red clay
•1.Date Well(s)Completed:
5 30 2023 36 ft• 80 ft• Saperlite
81 ft. 100 ft. Granite
S.Well Location: 101 ft• 200 ft. Granite
John laughter ft. . ft.
Facility/Owner Name Facility IDt:(if applicable) _ _.__ „ft y.. i " m+ft. . g—R {_A.n V.;-- / �._z j
400 sproles Smith rd Dallas nc I. n — '
Physical Address.City.and Zip I:.
'"21:RERIARKS;_,- '., .;. ..:•.)t.�l:_,l!)•( ?j-1n. -.. --
Gaston
County Parcel Identification No.(PIN) hull er,::a.r�,t 'a.;.=s4;;'ij l;r.,c
Sb.Latitude anti Longitude in degrees/minutes/seconds or decimal degrees: 22,Cer•tifieation:
(if well field.one lot/long is sufficient) ��7�
35°23'31..3188 N -- _ 81°07_'32.667.6"_ _--W �J'y/ --- 5/31/2023
Signature of Certified Well Contractor Date
6.Is(are)the wellaermanent or ❑TCtnporary By signing this form.1 hereby cerify that the trellis)was(were)corstntded in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consmtctian Standards and that a
7.Is this a repair to an existing well: ❑Yes o®No copy of this record has been prrrrided to the well owner.
If this is a repair..fill out known well construction infornuuior and explain the nature of the
repair antler/121 remarks section or on the back 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
S.Number of wells constructed: 1 conslmctiorl details. You may also attach additional pages if necessal .
For multiple injection or non•n•ater•supply tells ONLY with the sane construction.you can
submit 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
For nmhiple wells list all depths if different(example.3r,200'and 2C'/00) construction to the following:
10.Stalk water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
If water lend is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241),For infection 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.cable,direct push.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(gym) 40 Method of test: Air lift 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hype; Hth Amount: 12ounces completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depart mem of Ens•imnment and Natural Resources—Division of Water Quality Revised Jan.2013