GW1-2021-03511_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
1.Well Contractor Information:
Gary Justice 14.WATERZONEs ,
FROM TO DESCREMON
Well Contractor Name 100 fL 120 ft. 30 GPM
NCWC 2150-A
NC Well Contractor Certification Number 15'OUTER,CASING for multi cased wells OR:LINER if a" livable
FROM TO DIAMETER TffiCIINF,SS MA77R'AL
Justice Well Drilling Inc 0 ft- 150 fL 1 61/8 SDR 21 PVC
Company Name 16 IIVNER'CASINGOR TUBING: `eothermal closed-loop)
FROM TO DIAMETER ITHIGTQQESS MATERIAL
2.Well Construction Permit#: W20-0470 0 D• 81 ft. 4 `" SCH 40 PVC
List all applicable well permits(i.e.County,State,(variance,Injection,etc.) � ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT t E `
FROM I TO MA7't,•rriAr. EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 1 ft. Hole'Plug 1 Bag poured
Non-Water Supply Well: 1 R 21 fL Easy seal 1 Bag pumped
❑Monitoring ❑Recovery
Injection Well: 48 & 50 fL 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 g• ft.
❑Aquifer Test ❑Storrnwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control 20 DRILLING:LOG'attach additional'sheets if uecessa
❑Geothermal(Closed Loop) ❑Tracer R
To DESCREMON color,haMn aaUrxk size eta
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 45 ft' Dock& dirt
5/26/21 ft- 65 ft. Granite Quarts
4.Date Well(s)Completed: Well ID# ft.
70 Break of red water
5a.Well Location: 145 t" Soft Blue Granite
Frank Moore ft.
Facility/Owner Name Facility ID#(if applicable) ft•
715 Catawba River Rd Old Fort NC 28762 ,t R• 7 202
Physical Address,City,and Zip 21.RENIARKS.;`
McDowell 06590959940 hracessing
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Jignaturc
rtification:
(ifwell field,one lattlong is sufficient) 3
36.621011 N -82.193826 w 5/26/21
of ed ell tractor Date
6.Is(are)the well(s): RiPermanent or NTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with/SA NCAC 02C_0100 or/SA 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:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLPwith the same construction,you can
submit one form. SUBMITTAL INSTUCTiONS j
9.Total well depth below land surface 145 (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-33@200'and 2®1001 Construction to the following:
10.Static water level below top of casing: 30 (g•) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (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 Resour I,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceuter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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 Clorine 73°/amDunt: 8 oZ well construction to the county health department of the county where
type: constructed.
anti Natmal Resources—Division of Water Resources Revised August 2013