GW1-2021-00637_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD For Interred Coe ONLY:
This form can be aced for single or multiple wci[i
1.Well Contractor Information:
Gary Justice IA.WATER ZONES
FRUN TU DESCRIPTION
Well Contractor Name 75 "• 80 "• 1 GPM
NCWC 2150-A 250 H- 1 280 4 GPM
NC Well Contractor Cenifiwtme Number IS.OUTER CASING for dtl-cued wW OR LINER
FROM I I DIAMETER THICKNESS M11 MAT!Jtsi
Justice Well Drilling Inc 0 55 1 6 1/8'" SDR 21 PVC
Company Name 16.DINER CASING OR TUBING hermY elaredJ
SW19-0404 FROM TO DIAMETER THICKNESS MATERIAr
2.Well Construction Permit N: fit. n. ha.
Get all applicable adlprrmitr Rr.CmmN Sot,.V..ionoe,bjrctinn.rrrJ fit. fit. r
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public fl. fe in.
OGeathem it(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOCNT
❑lni ation 0 ft. 1 "• Hole Plug 1 BagPoured
Non-Water Supply Well:
OMonitaring ❑Recovery 1 ft- 21 "' MA seal 10 Bags pumped
Injection Well: 54 IL 55 " Hole IU 1 Bag Poured
❑Aquifer Recharge OGroundwater Remediatiun 19.SAND/GRAVEL PACK is
FROM TO MATERIAL ENIFLACTMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Battier ft fit
OAquifef Test ❑Storrnwater Drainage
H. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(a Is additloaal rYeeb B
DGeothermal(Closed Loop) OTraeer mom TO DESCRIPTION .1m stations, IV.k ope.and.alas cle.li
OGeothennal(Heating/Cooling Return) OOther(explain under#21 Remarks) 1 0 ft. 12 "' Rock &dirt
ft. ft.
Date Well 1/27/21 s)Completed: Well IDN 12 R• 45 "• Red Rock,Dirt
So.Well location: 45 "• 505 "' Granite Quarts
John Marshall ft. R.
FaclloyMoner Name Facility[Do(dapplicable) fit "
6701 Vein Mountian Rd,Nebo N.0 ft. ".
Physical Address,City,and Zip 21.REMARKS
McDowell 1626-00-16-4697
County Parcel Ideruificadon No.(PIN)
5b.Latitude and Longitude In degreeslininutestseconds or decimal degrees: 2 rtirication:
(if well field,arm lattong is sufficient)
35.547010 N -81.952468 w of C'em cd _ 1/27/21
igmture ell tractor Date
6.Is(are)the well(s):Xermane"1 or OTempors ry B,ei rain this g g - f rm,1 herrhr rernii thor the cell/I was rnrrr/rarulnared in accordance
r,with 15A.YCAC 0?C_0100 or 15A NCAC 02C 000 Well Con.rmmr,.a S madards and that a
7.Is this a repair to an existing well: []Yes or END ,,, ,f,h..rraorvl has hem prondrd ra rhr,rcll onurr.
f/this is a repair,fill out known ue!!ronsnvetinn iofarmoion and espluin the it.of the
repair,under 921 remnrks mr1..n or on the h.,rk ofthis(rm. 23.Site diagram or additional well details:
You Duty use the back of this page to provide additional well site details or well
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
f'or multiple injrctimr or nnn,wrrr supply usdls ONL}'n-itlr the sate Dons don,pnu ono
.e.hmit an,h+rm. F lSSUBMITTAL INSTUCTIONS
C-(R
9.Total well depth below land surface: 505 L fR o All Wells: Submit this form within 30 days of completion of well
for multiple wells list all deplh,ifdif ream fesmnple- and 26u,100'1 construction to the following:
10.Static water level below top of"sing: 60 l U X AL)L 021 Division of Water Resources,Information Processing Unit,
gwoer level is ahave rasing are"+" , TProces �rrr� 1617 Mail Service Center,Raleigh,NC 27699-1617
6 DVVR Sectios��Bitntectton Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter. find S@C(j0�
Rotary 24a above, also submit a copy of this (ono within 30 days of completion of well
12.Well construction method: '7 construction to the following:
it e...gen mmry,cable,direct push,oc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(glom) 5_. _.._ Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.1lisinfection type: Clorine 730/amouDF. 8 0Z well construction to the county health department of the county when:
constructed.
Form Gw-1 Noah Carolina Depanmenl of Environment and Natm-al Resources-Division of Water Reoounes Revised August 2013