GW1--06962_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD For internal Use ONLY: '
- lids form can be used for single br multiple wells 1
1.Well Contractor information: I
- Shane Gossett 14.WATER ZONES
FROM TO DESCRIPTION.
• Well Contractor Name 140 ft• 141 ft. i 2gpm
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• 3528-A . 289 ft. 290 IL 1 5912m
NC Well Contractor Ceniftcation Number 15..OUTER CASING(for multi;cusedlic114=OR-LINERQfiip Arabia-
FROM TO DIAMETER THICKNESS MATERIAL
McCall Brothers, Inc. 1 ft. 39 _.ft. . 6.25 'in. 0.25 Pvc
Company Name •16.iNNER CASING OR TUBiN.G.(neotherinal closed-loob)-'..'••.-.' •.-. '- ••
FROM TO - . DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ii: 14043 0 ft. ft. in.
Lit:all applicable well construction permits(i.s.County.State.Variance.etc.)
it ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER- SLOT SIZE THICKNESS. MATERIAL
0 IL ft. in.
❑Agricultural ❑r anicipaUPublic
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) R. fL In.
• • ❑Industrial/Commercial ❑Residential Water Supply(shined) 18,GROUT .•-
FROM. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation ft. ft.
Non-Water Supply Well:• •
❑Monitoring ❑Recovery • 0 fa 22 ft. 3entonite chips Poured from surface 1200lbs
Injection Well: ft. It.
❑Aquifer Recharge ❑GroundwaterRemediation •..l9;SAND/GRAVELPACK(ifapplicablc)
FROM TO MATERIAL EMPLACEMENT ME h OD
❑Aquifer Storage and Recovery ❑Salinity Barrier - 0 rt. H.
❑AquiforTest ❑SlonnwaterDrainage ft. ft.
❑Lxperinrenlal Technology 0 Subsidence Control' 20.DRILLING LOG(attach addiUnnal•shectsafneccssarvy..:'..::•
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(colar,hanlnecc.soil/ruck inc.grain sin.vie.)
❑Geothermal(HcatingfCooling Return) ❑Other(explain under#21 Remarks) 0 rt. 13 ft- Red clay
9 14 ft• 25 ft. ! saperllte
4.Date Wells)Completed: 5 2023 I I
26 ft• 30 ft- Sorry rock
5.Well Location: 31 ft. 40 ft. Granite
David Witherspoon 41 ft• 100 rt. Granite
Facility/Owner Name Facility ID#(if applicable)
101 ft. 300 ft. Granite
546 stockwoOd marks church rd Bessemer city nc rt. rt.
Physical Address.City,and Zip
.21.REMARKS i -.
Cleveland •;- a�, {- r.`� 1),
County Parcel Identification No.(PIN) •
OCT• c� 2023
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1 G
22
(if well field,one Iatilong is sufficient)
Certification: '
35°21'22.68" n nforciu it n:l'.� C•=,sir 7.3 US 5/11/2023
N 81°2011.3244 W 1 fiw W.-.1-.a
Signature of Certified Well Contractor Dale
6.Is(are)the wellalliermanent or ❑Tempor;u l' By.signing this font.I hereby cerify that the well(sy teas(were)consDncted in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes o•No• copy of this record has been provided to the well owner.
If this is a rcpair•.Jill on:known well constnretiom injrntralirmr and Crplain the nature of the •
repair under#21 remarks section or rat the back°J'(his form. 23.Site diagram or additional well details:
You may use the back of this page td provide additional well silo Mails or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary. .
For multiple Werth)))or not-water supply twits ONLY with the same construction,you can
submit one fora r. 24.Submittal Instructions:
9.Totalwell depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all de/tilts if different(example-3@200'and 2@•10O) construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Quality,Information Processing Unit,
If waters'level is above casing.use'•+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.Fur injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this for»within 30 days of completion of well
Air rotary constriction to the following:
Well construction method:
(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 Cenier,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Air lift 24c.For Water Summly&Geothermal Wells: In addition to sending the form to
the addrcss(cs) above, also submit r;nc1 copy of this form within 30 days of
13b.Disinfection type: 12ounces completion of well construction to the county health department of the county
1 Hth Amount: where constricted.
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Form OW-I North Carolina Dcpanmcnt of Environment and Nanard Resources-Division of Water Quality Revised Jan.2013