GW1-2021-01066_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD In,lm,mal h,,ONL\
I ht,lirrm can be used Err single or nnlGple it l is
1.Well Contractor Information:
Gary Justice 14.WATER ZONES
FROM to I DESCRIPTION
N,h(-nn ra,tor Nang 185 n. 190 rl. 6 GPM
NCWC 2150-A 200 220 n. 29 GPM
\C",If('nntraolnr('cnilican".Rumba 15.OUTER CASING likir mal6-caud weW)OR LINER Ifa Ikable
FRO\I To \ ETER Tlil('KSF.SS 51.\TLIAL
Justice well Drilling, INC o DI \I
52 1 61/8 1 SDR 211 PVC
l'omPa., Nana. Id.INNER CASING OR TUBING eRlhermd dosed-(tat
W20 0458 FROM DI\METEN CKNEU ERI\h
2.W ell Construction Permil It (1, ft.
Lae/l epp/inrhlr well pnmrir,rrr.(Dunn_Srurc 1 grime r.Inpa rirm_er..l
ft. ft. r^
3.W ell Cse(check well use): 17.SCREEN ft.
W'aler Supply Well: FROM Tr T(1 UI\METER SLOTMM 1'lll('KNESS 11ITE11,11
ft.
D.Agricuhural ❑Mbmicipal:Public
.
❑Gnnhcnn:d fllaningi'ouling Suppl}I �Residrntial\4':dcr Supply Uinglel ft. ft in.
❑Industrial Commercial ❑Re^idcnnal Water Supply(shared) 18.GROUT
FROM 10 \I AT-RI.\I. E)IPL\('E\(ENT METII(IUA AM(ICNT
❑ slim' 0 ft. 2 11. o e p ug 1 Bag Poured
Von-n-W'aler Supply Well:
❑.Mondoring ❑Rea„,er. 2 D. 22 D' Easy seal 3 Bags Pumped
injection Well: 55 b' 57 R' Hole Plug 2 Bags poured
❑Ayuiler Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK Bam linblI
MOM ft.
a1ATER1A1. EMPLACEMESr\IETR(ID
❑Ayuiler Storage and Reanen ❑Salinity Barrier ft. ft.
❑Ayuiler Test ❑Stonnwater Drainage
ft. ff.
❑Esperimenlal Technology ❑Subsidence Control
os
d Nar
(itt 2 nuY DRILLING LOG a additional sheen II' i
❑ rthm crallClo+xd Luopl ❑Tracer FROM na DeM-RIPnoN n.uY,..nv. ..,ih'rman t M.mcuv.s.m.
ElGeothemnal(Heating Cooling Return) ❑Other les lain under;Cl Remarks) 0 ft. 20 f'' Clay
1/12/21 20 f' 45 "' Lose Rock& Dirt
4.Date N'dl(s)Completed: Well ID# 45 f'' 225 n. Granite Quarts
52.Well Location: ft. h.
Dan&Doris Gilliam —
Facda,0,ne,Min, F-acilny ID-(,rapprcahl,)
6550 N.0 226 South Nebo N.0 28752 „
I'hysaal Address.Oo.and Lap 21.REMARKS
McDowell 17300321557
Co^n, Pared Id,nralaatioa No.1['IN)
5b.Latitude and Longitude indegrees/minutes/seconds or decimal degrees: 2 rlificalion:
ut,c,l l ti,ld.one I:a long i,wtbci,nu
35.646636 81 .918791 W. 1/12/21
tiiunamm ni(ani \Fdllu aor Dal,
6.Is(are)the%ell(s): Wermanint or ❑Temporan
tlr agnurg d^,pn r. 1 her,hr mniR rleu m,vellla .....mndr r rnuuv.raJ m e rrrJ ena
wrlr LilY(:d(-lid('.ill au•rrlil 1C1( n`Y ICldl IIL/I C.:nn..... ti/nnJurd.m.J'l e
7.Is this a repair to an existing well: ❑Yes or MNu rapt ul rho r,.vnl lrnc Arrn pr'ur rJ.J 4r lh,rl,ILncnaY.
U lint&a"I fill uuI knnun ,,I/.ondrunlun lnlbrmurlr:n ur.J e,dein.h,nenuro r:l Ih,
ropnl.ands 121 rcm,r.A,srcll.m.....in,his.Ao/Mo prrrrr. 23.Site diagram or additional well details:
1`ou may use the back of this page to prcrvid:additional Nell site details or well
S.Number of wells constructed: 1 construction details you may also attach additional paces if necessary.
Frr mulran,i,,,r I..rn yr mrmnmo sryrph v,11,ONL1'nnh the aantr,nastraorinn.rrar r tin
,uhrna rm,I,uan. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All "ells: Submit this furor within 30 days of completion of well
F...rrndnplcurlh li.,aell Jrprlr.11,1110,111 1,mmplr-i-u700 and'a tort'( IP�� constmctiun In the lidlow'ine.
16.Static water level below lop of casing: 40 :'Y L� Division of Water Resources,Information Processing Unit.
ll u,rto Iecd i,ahmr rr..In'.u„" �/ 1617 Mail Sen'ice('enter,Raleigh.NC 27699-1617
11.Borehole diameter: 6 (in.) f f U 246. •(' n Wells ONLY: In addition to sending the IUmr to the address in
1�� U �j,r abuse, also submit a ropv ul this form within 30 dav, of emnpleuon u(well
12.W'ell conslruclion method: Rotary 4`5 sIt 3 /ctiun to the lidluwing.
tt.e.auger.unary,cable,direct pu,h_etch r.t]hly p-
ss)qDivision of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY W-ELLS ONLY; @C 'On g(Jnjl 1636 Mail Service Center.Raleigh.NC 27699-1636
13a.field(gpm)__35_ Method of lese AI r 24c.For Water Supply&Injection Wells:
r� Also submit one copv of this Icahn within 30 days of completion of
13b.Disinfection type: Clorine 7JD�Q(mount: 8 o2 well construction in the county health department of the county where
canslrud rl.
F llmlliN-I North Carolina Ucpanmcm of P:ncironnl,m aral C:numl Nc,uurccs Di...ion of Nato Rcmur,a R,ciscd August_013