GW1-2021-00929_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD For Internal U. ONLA':
This form can be awed for singk or multiple wc&
1.Well Contractor Information:
Gary Justice 14,WATER ZONES
FRO'af I 'to 11DW141 '1110N
Well Contractor Name 1901t• r 200 n- 75 GPM +
NCWC 2150-A
NC WellCanttacior Certification Nurtd+rr IS.OLTPR CA,SWC(fsr rnnhi r rvtvralls (►ft LiNER iftii"
FROM i TO aLi,htETFR TIIICIC.\"FSS MATES":.
Justice well Drilling, INC 0 "' 1 121 n 6 1/8 '° SDR 21 PVC
C lame 16 Il�ER C IWNr-OR Tt1RING entherand chaird•Ibo o antpany
41030 FROM . it) DIAMETER TNICK.N CS atAT ft
Ltti all applicahle wilt permbrs ti.e.Count:;Suitt.l ariance.Injection.ere.)
n. n.
3.Well Use(check well use): t7,SCREEN
11°aterSlrpply Well: Fxosl ru ulVl11tk sl.uTslr� 111I NUNS NIATF.RIAL
OAgrricultural OklunicipalPublic n in.
17(3eothetmal(Heating/Cooling Supply) j(tesidential Water Supply(single)
❑IndustrialiCommercial CResidentiai Water Supply(shared) 10.GROUT
FROM t it/ t NiNt AIAI_ EMPLA('EMF.N9 METROD&AMOUNF
Clltri ation 0 ft. 2 ft. HOW Plug 1 Bag Poured
OMonilorinSnppk Well: 2 ti. 22 ft. Easy seal 10 Bags Pumped
1.�hlrnmitarin r l.�Reeove
Injection Well:
OAquifer Recharge UGroundwater Remediation 1 .SANDtGRA'VEL PACK If upp kable
FROM '1ln MAERL1L E11tPLNWEMFXTAIET1100
0Aquifer Storage and Recovery USalinityBanicr
ft. , rt.
0 All uifer Test OStonnwaicr Driinage
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if access
L 431cot rermal(Closed Loop) UTracer FROM To pF4CRIP ION Jostlar.hardriess.saturnatt kylpe.SnIftsin,etc.l�
OGeothermal(Hearin foolin Return) 00ther(explain tinder 021 Remarks) 0 n. 60 n. Clay Rock
2/12/21 60 't 115't Clay sand lose rock
4.Date Well(s)Completed: Well[lJk n. . [t.
Sa.Well Location: 115 ° 205 't Granite Quarts
Clayton &Kristen Stamey -- . ... _ ... . _,_ .
Facility10%mer Name facility 1139 fifapplicatt9c) (t. -
5420 Country Vally Rd -
n.
Pkwicaal Address.City.and Zip 21.REMARKS' "'-a-
Burke 41030
County Parcel Identification So.WIN
5b.Latitude and Longitude in degrees/minatestseconds or decimal degrees:
22. rtification:
(if well 5eid.one Lau'lang is cull i iemt
35. 583898 N -82.233282 W 4 2/12/21
W Signature of('rnt Well Ca star -- _ Dale
6.Is(are)the well(s): 'crmanent or 137femporary
Ur stieninar this f4m,I hen4n,rerti/i that the wrlltc)iris furrel a'onsiructed in accordance
is ith 154 N(:iC a?C.ollia nr l Sd NCAC ti?C.021st)Il ell Construction Standants mid rkat a
7.Is this a repair to an existing well: LI Ves or XNo ropy of this rrrnrd hiss 1n rut provided to the a r•11 nnner.
?f this is a rapair.,(ill our kn„°rt wall,imsow:•tinn iaJ:,artmtt,wj card rvphrba ahr nano t.f the
repair tinder F?I rswarkx section or an the hark al thin foam. 23.Site diagram or additional well details:
You may use the back of this page to provide additional Wrell site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple Itllce itM or non-traiff sppply it ills AVLY tartly the same construction.You can
Submit one farm_ SI;BMITTAL INSTUCTIONS
4.Total well depth below land surface: 205 (ft.) 24a. Far All Wells: Submit this form within 30 days of completion of well
For mithiple arils do all deprlu iffitterent teraaaple-4!a,2(0)'and_'iia.Iitir) construction to the foltouin3:
10.Static water level below top of casing: 40 Ift.) Division of Water Resources.Information Processing Unit.
ltuuter lesel&above ern.tang.use"+" 1617 Mail Service Center.Raleigh,NC 276"-1617
11.Borehole diameter- 6 24h.For Inigtion Well 0NLY: In addition to sending the fornn to the address in
Rota/ 24a above. also submit a copy of this form within 30 days of completion of well
IL Well construction method: l construction to the follouing:
ti.e.auger.rotary,cubic,dit"I push.c1c.!
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 276"-I636
13s.Yield(gpm) 75 Method of test: ,Air _ 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:nClorine 730/(A cunt: 8 oZ well construclion to the county hetdth department of the county where
constructed.
Form 1'iW.1 North Carolina Department of Environment and Natural Resources--Division of W'atcr Resources Revised Auglust2013