GW1-2021-03508_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
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1.Well Contractor Information:
Gary Justice 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 180 ft. 185 & 1/2G PM
NCWC 2150-A 400 fL 500 fL 1 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells DR LINER if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 ft 170 ft 6 1/6 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
SW 21 0060 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
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaUPublic R % in•
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MnRUL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 & 2 ft. o e p ug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22+ & Easy seal 10 Bags pumped
Injection Well: 160 fL 170 & Hole Plug 1 Bag pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if"a"licab`le x Ai c° ;�
RUII. EMPLACEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft MATE METHOD
❑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,soil/rock type,grain sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 110 ft- Lose Rock& Dirt
a.Date Well(s)Completed: 5/17/21 well ID# 110ft• 505& Granite Quarts Granite with red
ft. ft. rock streaks
5a.Well Location: ft. ft.
Keith& Ashley Smith The Arbor lot 97 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
40 Cordova Dr Nebo N.0 28761 ft. ft.
Physical Address,City,and Zip 21 REMARKS
McDowell 171300966441 !ri#arrac;L t-imening
it �;.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: rtitication: '
(if well field,one lattlong is sufficient) 22. 4
35.736988 N -81.966321 W 5/17/21
Signature of Well Co ctor ' 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#21 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@100') construction to the following:
10.Static water level below top of casing: 60 (fL) Division of Water Reso
urces,ources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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
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13a.Yield(gpm) 2 Method of test: Air
24c.For Water Supply&Injection Wells!
Also submit one copy of this form within 30 days of completion of
13b.Disinfection typeClorone 730/9 Amount• 8 oZ well construction to the county Health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013