GW1-2021-00860_Well Construction - GW1_20210404

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 DESCRIPTION
Well Contractor Name 245 It. 260 a 1/2 Igpm
NCWC 2150-A 560ff 670 rt 24 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased we0s OR LINTER [ `lti abk - ..
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft- 136 a 61/8'° 1 SQR 21 1 PVC
Company Name 16.INNER CASING OR TUBING eotherma]dosed4o'
763528 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
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 in.
tt. rt. in.
❑Geothermal(Heating/Cooling Supply) CgResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM J TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ini'ation 0 ft. 1 1 Hole Plug 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft. 21 ft- Easv seal 2 Bags pumped
Injection Well: 136 It. 136 ft. Hole plug 1 Bag Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if r liable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. rL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.satUrock type,grain An etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. 130 rt• Rock& dirt
4.Date Well(s)Completed: 3/3/21 Well 1D# 130t• 605 tt• ,,Very-soft'-Granit streaks of
ft. fL
Quarts ,mics,soft granite
5a.Well Location: ft. !L
Tyler A Buchanan ft.
Facility/Owner Name Facility ID#(if applicable) fL _
66 Skyhook Lane,Slor 4 CR,r e-,t�e�8777 ft. ft- APR ,X
Physical Address,City,and Zip 21.REMARKS
Avery 181100246690 Information Processing Unit
County Parcel Identification No.(PIN) DWR Seclion
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(if well field,one lat/long is sufficient)
35.951715 N -81.997990 w 1 2/24/21
'ignature of Ccrti Ned ell tractor Date
6.Is(are)the well(s): Permanent Or ❑Temporary Br.signing this jnrm,i hereby certfi,that the net/(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Y'es or ®No copy of this record has been provided to the well oweter-
lfthis is a repair.fill out known well construction information and explain the nature ojthe
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 nith the same construction.you can '
submit oneform. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fftli'erent(exrtnrple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 100 (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 (in.) 24b.For Infection Wells ONLY: in addition to sending the form to the address in
Rotary 24a above, also submit a copy oI'this form within 30 days of completion of well
12.Well construction method: '1 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(gym) 25 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 Natural Resources—Division of Water Resources Revised August 2013