GW1-2021-01836_Well Construction - GW1_20210503

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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.WATER ZONES t J
FROM TO DESCRIPTION
Well Contractor Name 360 IL 350 ft- 1/2 GPM
NCWC 2150-A 475 ft 485 ft- 59 112 GPM
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wells OR LLVER f Ifeatlle
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 IL 1108 ft. 6 1/8 In. SDR 21 1 PVC
Company Name 16.INNER CASING OR TUBING thermal cloud-loo
17798 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ' io.
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 Weil: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
ft. ft.❑Geothermal(HeatinglCooling Supply) RResidential Water SuPPtY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OhTigation 0 ft 1 " Hole Plug 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 It 21 ft Easy seal 2 Bags pumped
Injection Well: 106 ft• 108 ft- Easy seal 1 bag Pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ff avolleablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHODft ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,mlyrock rain size etc.
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 97 ft. Rock& dirt
4.Date Well(s)Completed: 4/26/21 Well ID# 97 ft 103 ft- Soft rock and dirt
103 ft 505 ft- Granite Quarts
Sa.Well Location: M ft
Erik McCarrin ft ft.
Facility/Owner Name Facility IDO(if applicable) ft ft.
2532 Wolf Pit Rd Morganton N.0 28655 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Burke Ay
County Parcel Identification No.(PIN)
Ifcfr at cn pmr-ess)ncg. r '
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification: V
(if well field,one lat/long is sufficient)
35.812300 N -81.878663 W 4/26/21
vigmtureofCem ed ell ttractor Date
6.Is(are)the well(s): XPermanent or ❑Temporary
B..signing this farm,I hereby certify,that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well otmer.
-'-f this-is a repair,fill outknow7t well construction irrfonnation and explain the native of'the -
repair under#21 remarks section or on the hack of this farm. 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 at additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction, can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (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: 60 (ft.) Division of Water Resou`t cis,Information Processing Unit,
Ifwater level is above casing,use^+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: 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: 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) 60 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this forms within 30 days of completion of
Clorine 730/ 8 oZ well construction to the county health department of the county where
13b.Disinfection type: amount: I
constructed. '
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013