GW1-2021-00866_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 680 ft- 700 ft- 1/2G PM
NCWC 2150-A 750 ft• 760 ft- 1/2GPM
NC Well Contractor Certification Number 45.OUTER CASING fair multi eased,wells OR LINER ita ticab►e
FROM TO D64�IETER. THICKNESS MATERIAL
Justice well Drilling, INC 0 ft. $4 ft- 61/8 iti I i SDR 211 PVC
Company Name 16.INNER CASING OR TUBING cothermal dosed-loo`._
57325 FROM TO DIAMETER THICKNESS MATERIAL
2.well Construction Permit#: ft ft. in•
List all applicable well permits r.e.Coun y,State,Variance,hyection,etc)
tt. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER', SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mttnicipal/Public ft. it. in.,
❑Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft. ft. in.
❑lndustriaVCommercial ❑Residential Water Supply(shared) is.GROUT
FROM I TO IATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 2 ft. mole plug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft' 22 ft- Easy seal 1 Bag Pumped
Injection well: 83 ft• 84 ft- Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remedialion 19.SAND/GRAVEL PACK C a 0heable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets itneeessary
❑Gcothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness.soil/rack type.grain size.eta.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 ft- Clay
3/12/21 20 ft- 45 fL Clay sand lose rock
4.Date Well(s)Completed: VI'eIl ID#
45 ft- 74 ft- Rock &'dirt
5a.well Location: 74 ft. 805 ft- Granite Quarts
David & Marilyn Varnes ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2032 Ferguson Folly Dr. Nebo N.0 28761 ft.
Phvsical Address,City,and Zip 2I:REMARKS
Burke 57325
County Parcel Identification No.(PIN) S at1o�Processing
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 rtification: D
(ifwell field,one lat/longis sufficient) -82 894868 3/12/21
35. 748740 N w
Signature ofCeni Well CoiUctor 4. Date
6.is(are)the e'ell(s): tRhermanent or ❑Temporary By signing this form,1 herebv certijv that the well(.$)has(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 lVell Conn uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or XNO copy of this record has been provided to the we/1 owner.
If this is a repair.fill out known well consiniction 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 midtiple injection or ion-water stipple wells ONLY wiih the same construction,You can
submit one form. p C SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 805 (ft,) 24a. For All Wells: Submit this' forth within 30 days of completion of well
For i n ltiple wells list all depths ijdi jfereni(example-3@200•and 2@100) construction to the follo%Ang:
10.Static water level below top of casing: 100 (ftJ Division of Water Resources,Information Processing Unit,
1f renter 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
Rotate 24a above, also submit a copy of�Ais 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 C i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test:
Air 24c.For Water Supply&Injection Wells-
Also
Also submit one copy of this form xithjnl 30 days of completion of
13b.Disinfection type: Clorine 73%,mount: 8 oZ well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013