GW1-2021-00868_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary llStlCe 14.WATER ZONES x
FROM TO I DESCRIPTION �± tt
Well Contractor Name 15555 1- 225 ft` 1/2 GPM
NCWC 2150-A 3601- 370 ft. 31/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for malfi cased wells'OR LIAiER iicabk
FROM TO DIAMETEBpR THICKNESS MATERIAL
Justice Well Drilling Inc 0 It 100 6 1/8 in' 1 SQ' R 21 PVC
Company Name 16.LNNER CASING OR TU$ING feeathermal closed-loopl
�2230 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: _ ft. ft. In.
List all applicable tiell permits(i.e.County,State.Variance.injection,etc.) _ t inft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA4
OAgrictdtural OMunicipal/Public ft. ft. in.
ft. f in.
OGeothermal (Heating/Cooling Supply) gResidential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
olrri ration 0 ft. 1 It. Hole Piu 1 Ba poured
Non-Water Supply Well:
[]Monitoring 0Recovcry 1 ft. 22 H. Easy seal 2 Bags pumped
Injection well: 46 fL 48 e. Hole plug 1 bag Poured
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SANDiGRAVEL PACK if applicable)
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test OStonnwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG attach additional slutts if uttessa
❑Geothermal(Closed Loop) [!Tracer FROM To DESCRIPTION ftolar hardness,sstvrock t to sire ett.
0Gcothermal(Heating/Cooling Return) []Other(explain under 421 Remarks) 0 iL 80 ft. Rock&dirt
4.Date Well(s)Completed. 3/22/21 Well iD# 80 rL 95 it- Lose Rock
95 ft 405 f- Soft Granite Quarts
5a.Well Location: ft. ft.
Jeff&Anna Jordan C/O Mcgrath 1780 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1479 Yellow Fork Trail west Nebo N.0 ft. ft.
Physical Address,City„and Zip 21.
Burke 1
County Parcel Identification No.(PIN) r 11processing
5b.Latitude and Longitude in degrees/Ininutes/seconds or decimal degrees: 2 rtifiication: IDVVR BC
{if well field,one lattlong is sufficient}
-81.901324 W — 2/22/21
35.77729 N
ignature of Cen red rell tractor Date
6.Is(are)the well(S): OPermanent or OTemporary Av signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA AtCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or IRNe copy gfthis record has been provided to the well awner.
Ifthis is a repair.,rll out know7i well construction information and explain the nature ref the
repair under#21 remarks.section m-an the hack gfthisform, 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 i€necessary.
For multiple injection or non-water suplih•tivils ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this;font within 30 days of completion of well
For multiple welts list all depths ffdifferent(example-3@1200'and 2(a;100`) construction to the following:
10.Stack water level below top of casing: 60 (ft,) Division of Water Resources,Information Processing Unit,
If water level is abasw cashig,use"+'. 1617 Mai!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: 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) 4 Method of test:
Air 24c.For Water Supply&Injection Weds:
r
Also submit one copy of this font within 30 days of completion of
13b.Disinfection type: Clorine 730/%-tttount: 8 oz well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural sources-Division of Water Resources Revised August 2013