GW1-2021-03504_Well Construction - GW1_20210607

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
..xl
FROM TO DESCRIPTION
Well Contractor Name 475 ft- 480 ft- 3 GPM
NCWC 2150-A ft. ft. j
NC Well Contractor Certification Number 15..OUTER CASING for mu16-rased;wells OR LINER if applicable)
FROM TO DIAMETER THICKNESSI MATERIAL
Justice well Drilling, INC 0 ft- 1 64 ft 6 1/8' SDR 211 PVC
16.INNER CASING OR:TUBING(geothermal closed-loop)Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: SW20-0496 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
Water Supply Well: FROM TO DIAMETER. ...SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft• fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft 2 ft. o e�p ug 1 Ba Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22+ ft. Easy seal 10 Bags pumped
Injection Well: 62 ft. 64 ft- Hole Plug 1 Bag pumped
❑Aquifer Recharge ❑GroundwaterRemediation 19.;SAND/GRAVELPACK'(if a"Iicablb) 7.
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
& ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach addition alsheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 58 ft. Lose Rock& Dirt
a.Date Well Well ID#s)Completed: 5/28/21 58 ft 505 ft Granite Quarts
ft. ft.
FCC)
5a.Well Location: ft. fL
Barry Gupton ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. J�
2428 Old Fort Sugar Hill Rd, Old Fort_ ft. tt
Physical Address,City,and Zip 21.REMARKSRec0n
McDowell 066800682631
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification: At
(if well field,one
35.6004100 g is sufficient)N -82 141372 W O t� '. 5/28/21
Signature of Certi Well Co ctor i Date
6.IS(are)the well(s): permanent or ❑Temporary By signing this form,I hereby certify that the well(s)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 KNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: )60 Division of Water Resources,Information Processing Unit,.(ft
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 1/8 (in) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary
24a above, also submit a copy of(this form within 30 days of completion of well
12.Well construction method: 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
`3 m Method of test:
13a.Yield
(gP ) Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form:Within 30 days of completion of
13b.Disinfection typeGlorine 73oo Amount: 8 oZ well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources ` Revised August 2013