GW1-2021-00604_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATER ZONES
IRON TO DESCRIRION
Well Contractor Nana: 160 fl' 190 "• 5 GPM
NCWC 2150-A 130fL 1 150 "• 70 GPM
NC Well Cmus rne-C'enifirmum Number IS.OUTER CASING for ma4Feaaed wells OR LDSER N
FROM TO DIAMETER TRICKNFSS MATERIAL
Justice Well Drilling Inc 0 72 6 1/8la 1 SDR 21 1 PVC
Company Name IC INNER CASING OR TURDYG hermYat
SW17-0109 FROM TO DIAMETER TNICKNFSS MATERIAL
2.Well Construction Permit#: tL ft. in.
List all applicable uvll permits h e.C'oures.Stare. f'arimu e.Injection.es,:l fL h. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIAMETER SLOT91r T WI NESS MATER"L
OAgricultural ❑MunicipaUPublic "• "
OGeothermal(Heating/Cooling Supply) RResidential Water Supply(single) h• I h• in.
❑bdustrial,Commercial ❑Residential Water Supply(ehared) 1L GROUT
FROM I TO MATERIAL I EMFLACEMENTMETROD&AMOUNT
01irrigation 0 IL 1 "• Hole Plun 1 Bag poured
?loll-Water Supply Well:
OMoniwn g CIRmovery 1 "' 21 "• Easyseal 10 Bags pumped
IRjeeRma well: 89 6 92 "• Hole plug 1 Bag Poured
OAquifef Recharge OGruundwater Remediation If.SANDIGRAVEL PACK
FROM TO MATERIAL EMELACEMENrsilwoe
OAquifer Storage and Recovery OSalinity Barrier ft ft
OAquifer Test OStormwater Drainage
h. h.
❑Experimental Technology OSubsidence Control
21L DRILLING LOG ahaeh additional shares if
OGeothermal(Closed Loop) OTracer FROM TO DESCIFUYTION ne,lor,hardstas.,aD',eek gym,arms sins ate.
OGeothermal(Heating/Cooling Return) OOther(explain under421 Remarks) 0 fL 12 "• Rock & dirt
4.Date Well(s)Completed: 1/15/21 Well ID# 12 n- 40 "• Clayrock
p 40 "• 85 "• Red Rock,Dirt
5s.Well Location: 85 fL 165"• Granite Quarts
James Stamey ft. h.
Fardoy Owner Name Facility lDa(ifapplicabk) ft ft
1225 Mackeys Creek Old Fort 28762 ft. ff.
Physical Address.City,and Zip 21 REMARKS
McDowell 0761-00-72-9637
County Parcel Identification No.(PIN I
5b.Ladfude and Longitude in t egres slminutes/seconda or decimal degrees: rflOCsdon:
(if well field,one ImIlong u suRcknO
35.668555 N -82.139012 W 1/15/21
-
igtnmre of Cem Iasi ell vapor Date
6.Is(are)the weil(s): ermaneot or OTemponn' He .signing this/orm. 1 harelo ceraA rhur the uvills/ was(were/,mutrucled in ..i'adanoe
wilh 15A h'CAC 02C0100 nr ISA h'C'AC 02C,0200 Well Coast ruetian 9mal rds and that a
7.Is this a repair to an existing well: ❑Yea or KNo cape 4 this record has been provided to she sell oumer.
lrthis is a repair.fill out known well ronstrucriun information and explain the ninon of the
repair tinder d21 remark,set then or on the lack n/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 construction details. You may also attach additional pages if necessary.
For multiple inledua,ur non-outer supply wells ONLY with the sense ronahurNen.1'ou,vn
. SUBMITTAL INSTUCTIONS
.,.limit m,form
9.Total well depth below land surface: 165 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
Far multiple ovals list all depths if dilferem(example-3u:200 aml 2a,l00') construction to the following:
10.Static water level below lop of casing: 30 RECENEp Division of Water Resources,Information Processing Unit,
11 ware,l,,rl u above,.mg.wee I ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) F F H X 5 2 For Infection Wells ONLY: In addition to sending the form to the address in
Rotary ahove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 'Y •?' S c�truction to the following:
(i.e.auger.rotary.cable,direct push.etc.) ✓R Section 9�iviiion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 75 Method of ,,: Air _ 24c.For Water Supply&laiection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type, Clorine 730/ammint: 8 oz well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of En"mntrcnl and Natural Resumes-Division of Water Resources Revved August 2013