GW1-2021-00867_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD For lntemal Usc 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 890 fL 695 It. 6 GPM
NCWC 2150-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for inalti-cased wells'OR Lis�iER f a cablt 7
FROM ?O DIAMETER i 7TIICICNESS MATERIAL
Justice well Drilling, INC 0 ft 1 138 ft 61/8 in- SDR 211 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
62230 FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#:____.__ ft ft.
Lest all applicable well permits Ae.Counm State.Variance,hyection.err.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DMMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single)
ft. R. in. i
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROVI f
FROM I TO RIAL EMPLACEMENTMETHOD&AMOUNT
Clbri ation 0 rt. 2 R. Role plug 1 Bag Poured
Non-Water Supply Well: 1
ft. 22 ft S EASY seal 2 Bags; umped
❑Monitoring ❑Recovery 2
Injection Well: 136 ft• 138 it. Hole plug 1 bag poured
❑Aquifer Recharge •❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fl.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If access
ClGeothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION coMr haven toiVratt a 'rain silt tee.
❑Geothermal(Heating/Cooling Return) ❑other(ex lain under#21 Remarks) 0 it. 128 R, CI6Y
4.Date Well(s)Completed: 3/19/21 well IDt: 128 ft. 132 "• Clay sand lose rock
132 ft. 705 fL Granite Quarts
5a.Well Location: ft. ft.
Joseph & Sandy Dyer C/O Mcgrath ft. fL
Facility/Owner Name Facility lD#(ifapplicable) ft. R. p
1497 Yellow Fork Trail W
Physical Address,City,and Zip 21 REMARKS
Burke Lot 209
County Parcel Identification No.(PIN)
¢ rr�,atlan Proses
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
{ifweA field,one tattlong is sufficient)
35. 746869 N -82.901334 W ��1 3/19/21
Signature of rti Well Co ctor Date
6.is(are)the well(s): ppermatrent or ❑Temporary• «Lhis f
YY 11v signing this form,I hereby rerrifi,that;dtc nelf(sJ arts(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA VCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or NNa copy of this record bets been provided to the well owvrer.
If this it a repair,fill out known well construction igffinnation and explain the nature of die
repair under#21 remorkrsection or on the hack gjthis,j rm. 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 ngection or non-water suoop if wells ONLY with the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 249. For All Wells: Submit this forma within 30 days of completion of well
Far mutiple wells list at!depths ifdifJereut texample--J a @)f200'and 2100') construction to the following:
10.Static water level below top of easing: 95 (ft.) Division of Water Resources,Information Processing Unit,
l(water level is above rasing,use"+" 1617 Mail Service CcInter,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotai�' 24aabove,also submit a copy of this form within 30 days of completion of well
IL Well construction method: '7 construction to the following:
(i.e.auger,rotary,cable•direct push,etc.) I
Division of Water Resources,IJDdergroand Injection Contra)Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a,Yield(gpm) 6 Method of test:
Air 24c.For Water Supply&Injection Wells:
ou 8 Also submit one copy of this farm within 30 days of completion of
13b.Disinfection type: Clorme 73OXAmnt• oz well construction to the county hetilth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of W oter Resources Revised August 2013
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