GW1-2021-03509_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD
For Internal Use ONLY: r
This form can be used for single or multiple wells
1.Well Contractor Information:
GaryJustice 14.WATER ZONES
7 FROM TO DESCRIPTION
Well Contractor Name 190 ft. 193 60'GPM
NCWC 2150-A ft& ! '
NC Well Contractor Certification Number
15.OUTER CASING for tnulti-cased wells Oab LINER if a 6eable
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 it 1 62 ft 6 1/8 in. SDR 21 PVC
Company Name 16.INNER CASING OR TUBING "eothermat closed-loo'
W21-0177 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 SE THICKNESS MATERUII
❑Agricultural ❑Municipal/Public ft. ft. in. IZ
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft' ft. m.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
oIrrigation Non-Water Supply Well: 0 fr 1 & Hole Olu 1 Bag poured
❑Monitoring ❑Recovery 1 fL 21 fL Easy seal 1 Bag pumped
Injection Well: 60 ft- 62 & Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK:'if a"`liable , ?; _
CEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLA METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addiNoital sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soiltmck type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 57 ft- Rock & dirt
4.Date Well(s)Completed: 5/18/21 Well ID# 57 & 245 fL Granite Quarts
ft. fL
5a.Well Location:
ft. ft. r�-
Gary Richter ft. �.
m�
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
163 Shangrila Dr. Nebo 28761 ft. ft.
Physical Address,City,and Zip 21.REMARKS- Processing
McDowell 172200399580 QVVR Sec"On
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification•
(if well field,one lat/long is sufficient) ti
35.720020 N -81 .951753 W f 5/18/21
ignMwe of Cerh ed rell atractor ' Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this form,I hereby certij�y that the well(s)was(were)constructed in accordance
with 1 SA 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 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 thisform. 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
i
9.Total well depth below land surface: 245 (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: 160 (it) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotate 24aabove, 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
m 13a.Yield
(gP ) 60 GPM 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 type: Clorine 730/amount• 8 oZ well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Na Resources—Division of Water Resources Revised August 2013
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