GW1-2021-03503_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
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1.Well Contractor Information:
Gary Justice 14.FROM ER ZONES t
FROM TO DESCRIPTION
Well Contractor Name 200 ft' 220 ft' 1/2G''PM
NCWC 2150-A 505 ft 520 ft 1/2GPM
15.OUTER CASING for multi-cased;wells OR LINER if a licable
NC Well Contractor Certification Number FROM TO DIAMETER, THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft 60 ft 6 1/8 in SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
W21-0244 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc) ft. ft in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in..
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM
GROUT
FROM TO MATERIAL' !EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft. 1 ft. Hole Plug 1 Bag poured
Non-Water Supply Well: 1 ft. 21 ft. Easy'seal 1 Bag pumped
❑Monitoring ❑Recovery
Injection Well: 52 ft 60 f� Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
6/02/21 0 f`• 55 ft• Dirt Rock
4.Date Well(s)Completed: Well ID# 55 ft. 705 ft Granite Quarts
5a.Well Location: ft. ft.
Creston John Nelson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. a5 g
,1029 Kestrel Lane ,Black MountianjuN
Physical Address,City,and Zip 21.REMARKS
McDowell 0637008927 ,essing unit
County Parcel Identification No.(PIN) 0u'411 Seviia?n
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(if
35. 18ff g is sufficient)
57556 N -82.233700 w
6/02/21
ignature of Cern ied rell Tractor Date
6.Is(are)the well(s): XPermanent or XTemporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy ofthis record has been provided to the well owner.
If this is a repair,fill our known well construction information and explain the nature of the 23.Site diagram or additional weal details:
repair under;t21 remarks section or on the back of this form.
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may alsoattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
'For multiple wells list all depths if difterent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY In addition to sending the form to the address in
Rotor 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 GPM Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
Clorine 73°/amount: 8 oZ well construction to the county health department of
llib.Disinfection type: the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water,, Revised August 2013
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