GW1-2021-03510_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
FROM TO DESCREMON
Well Contractor Name 140 ft- 150 ft- i 20 GPM
NCWC 2150-A ft. ft. F
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a`ficable
FROM TO. DIAMETER ;THICKNESS MATERIAL ,
Justice well Drilling, INC 0 ft 88 ft g 1/8 in. I SDR 21 PVC
Company Name 16.INNEWCASING`ORTUBING "eothermalclosed400
SW20-0360 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
It. fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERLAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. It. in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO -MATERUL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 2 ft Hole, plug 1 Bag Poured
Non-Water Supply Well:❑Monitoring ❑Recovery 2 ft- 22+ ft. Easy seal 10 Bags pumped
Injection Well: 84 fL 88 fL Hole Plug 1 Bag pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.:SAND/GRAVEL PACK if a "licable°
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock qM grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 80 ft- Lose Rock& Dirt
5/19/21 80 ft' 185 ft' Granite Quarts
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. It.
Jake Angi ft. f
Facility/Owner Name Facility ID#(if applicable) t C
407 Sedona Dr Nebo N.0 ft. ft.
Physical Address,City,and Zip 21.REMARKS
McDowell 174000775231 jrifon .,3,io t rG �3
a
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification
(if well field,one lat/long is sufficient)
35.659847 N -81 .870049 W 4 5/19/21
Signature of Certi Well Co ctor Date
6.Is(are)the well(s): l�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 1l9N0 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: 185 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdii erent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of lthis form within 30 days of completion of well
12.Well construction method: ry 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
13a.Yield(gpm) 20 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 typeClorine 7aOJo Amount: 8 oZ well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water resources Revised August 2013