GW1-2021-01793_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: t
Gary Justice 14.WATER ZONES
WA n0ft-
DESCRIPTION
Well Contractor Name ��� LVb� 1 "L 3 GPM
NCWC 2150-A 1��Y
����'''-'�• 5 "• 9 GPM
15.OUTER CASING fur multi-cased wells OR LINER if a 7"ble^�c,` ^y��i0
NC Well Contractor Certification Number �111vx1 +t .. PROM TO THICKNESS MATERIAL DIAMETER
Justice well Drilling, INC 0 ft• 80 ft 6 1/8 'i SDR 211 PVC
Company Name Ili.INNER CASING OR TUBING(geothermal closed-1`
W21 0054 FROM? TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ________ __....______.•_.._...._.�.__......_.___._ ft. ft. in.
List all applicable well permits(i.e.Counr)c State..Variance.injection.etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) iffiResidential Water Supply(single)
❑htdustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO i TRIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 M 2 ft. o e p ug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22 ft. Easy seal 2 Bags pumped
Injection Well: 78 ft, 80 ft. 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
❑Aquifer Test ❑Smmiwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessaryl
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION coins hudaeee soiVrock type,rmin size Ftt.
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) 0 ft, Ei5 ft. Red clay
4/02/21 65 rt 75 Lose Rock& Dirt
4.Date Well(s)Completed: Well ID# 75 ft. 225 H• Granite Quarts
5a.Well Location: ft. ft.
Tim &Melissa Nealley ft. ft.
Facility/Owner Name Facility ID8(if applicable) ft. ft.
2896 Old Greenlee Rd Marion N.0 28752
Physical Address,City,and Zip 21.MIARKS
McDowell 078102862223
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22. rtification:
(ifwell field,one Iat/long is sufficient)
36.678731 N -82.070136 W u✓J -t• _ 4/02/21 _
Signature of Certi Well Cv ctor Date
6.is(are)the well(s): permanent or ❑Temporary _ #v signing this form I herehv certify mar the nell(s)was(were)consirricted in accordance
,rich 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that is
7.is this a repair to an existing well: ❑Yes or 0KNo ropy ofthis recard has been provided to the well owner.
If this is a repair,fill out known tiedl construction iglbrinmion and eiplain the nature of the
repair tinder#21 remarks section or on the hack of this form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,t•ou can -
s SUBMITTAL INSTUCTIONS
subnrit one(arm.
9.Total well depth below land surface: 225 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if driferent(example-310;200'and 2(;100•) construction to the following:
10.Static water level below top of casing: 12 (ft,) Division of Water Resources,Information Processing Unit,
If aster level is above casing.rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
it.Borehole diameter:
6 1/8 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method: '7 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) 12 Method of test: Air 24c,For Water Supply&injection Wells:
/•� Also submit one copy of this form!within 30 days of completion of
13b.Disinfection typeClQrina 7.qo Amount; 8 oz well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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