GW1-2021-00862_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 ft. ft.
NCWC 2150-A i
NC Well Contractor Certification Number 15.OUTER CASING for multi rased surds Olt LINER if ii liceble
FROM TO DIAMETER THICKNESS AATERIAL
Justice well Drilling, INC ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothertualelosed400
WIO1OO613 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Cowin,State,Variance,h7jection,etc)
0 ft- 305 it• 1 1/4 -On- 3/4 Mistet Plastic
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) iS.GROUT
FROM TO- tATERIAL EMPLACEMENT METHOD&%,MOUNT
❑ini*ation 0 R. 2R. o e plug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22 R• Easy seal 20 Bags pumped
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionatsheets if neces4an•.
RGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type, rain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 70 ft- Clay
4.Date Well(s)Completed: 3/24/21 Well ID# 70 ft- 305 ftgranite
ft. ft.
5a.Well Location: ft. ft.
Enest James & Rachel Green Showfety ft. R.
Facility/Owner Name Facility ID0(if applicable) ft. ft.
30 Bee Balm Way Ashville N.0 2380y PR 20
Physical Address,City.and Zip 21.REMARKS
Buncombe InInfMatron Process►n
County Parcel Identification No.(PIN) p
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 rtifrcation:
(if%vell field,one Iat/long is sufficient)
35. 654492 N -82.610148 �� 4 3/24/21
Signature ofCerti Well CcoVctor i Date
6.Is(are)the well(s): ll'ermanent or ❑Temporary By signing this fornr, l hereby certify That the wells)it-as(were)constructed in accordance
with 15.4 NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or HNo copy of this record has been provided to lire well owner.
if this is a repair,fill out known well construction information and explain lire nature of the
repair under p21 remarks section m•on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nuthiple injection or non-neater suppty wells ONLY frith the same construction,ymr can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple cells list all depths ifdijferent(example-3@)200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfrwvater•level is above casing,rise•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 7/8 (in.) 24b.For Injection Wells ONLS: 'In addition to sending the form to the address in
Rota�/ 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: '7 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
139.Yield(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: Amount: well construction to the county f health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Wat Ir Resources Revised August 2013