GW1-2021-00865_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 A4.AIATERZONES
FROM TO DESCRIPTION
Well Contractor Name 155 rL 225 fL 1 GPM
NCWC 2150-A 245 fL 300`L 114 GPM
NC Well Contractor Certification Number 15.OUTER CASING for ells multi cased�e OR NER.ita ticrible
FROM TO DIAMETER THI LICKNESS MATERIAL
,Justice Well Drilling Inc 0 ft- 1 48 n 6 1/8i" iSDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal,closed-lob
33792 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft• ft. in.
List all applicable[cell 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 SITE THICKNESS MATERIAL
ft. rt. in:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) CgResidential Water Supply(single) 'm Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD 6 AMOUNT
❑hTiaation 0 ft. 1 ft- Hole .Plug 1 Bag poured
Non-Water Supply Well:
DMonitoring ❑Recovery 1 ft. 22 ft EaS seal 1 Bags
Injection Well: 46 It- 48 n Hole Plug 20 Bag Poured
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a' licble
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier M ft.
DAquifer Test ❑Stormwater Drainage
e, rt.
OExperimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary
OGeothermal(Closed Loon) ❑Tracer FROM TO DESCRIPTION color.hardnes soillroek type,•rain site,etc.
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft. Rock& dirt
4.Date Well(s)Completed: 3/1 5/21 Well no 10 fL 40 R Lose Rock
40 ft 305 ft• Soft Granite Quarts
5a.Well Location: ft. ft.
Micheal Sacosky ft. ft.
Facility/OwnerName Facility ID;#(ifapplicable) ft. ft
4210 River Rd Morganton N.0 28612 ft. ft.
ffhu
Phvsical Address,City,and Zip 21.REMARKS,. A
Burke -inun1c
County Parcel Identification No.(PIN) InTormijuvi, StyCt:Qn
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: PCV
rtification:
(ifwell field,one IaVlong is sufficient)35.662028 N -81.575164 W _ 3/15/21reofCened ell rtractor ' Date
6.Is(are)the well(S):NPCrmanenf or OTemporan t iBw signing this form.I hereby certi,that the we/l(v)was(here)constructed in accordance
with 15A AICAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or INNo copy of This record has been provided to the well owner.
if this is a repair,ill out known well construction information and explain the nature of the
repair under V I 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 irgection or non-water supply wells ONLY with the same construction,you can
submit one font. 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 wells list all depths if di(ferenl(example-3CM200 and 2C100) construction to the following:
10.Static water level below top of casing: 100 (ft,) Division of Water Resources,Information Processing Unit,
If water lewel is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells ONLY:S 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: Rotary 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) 15 Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this loon;within 30 days of completion of
13b.Disinfection type: Clorine 730/amount• 8 oZ well construction to the county h6(th department of the county where
constructed.
E
Form GV1n-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013