GW1-2021-01870_Well Construction - GW1_20210503

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Clary Justice 14.WATER ZONES,.
FROM TO DESCRIPTION
Well Contractor Name 175 ft. 180ft- 1/2 GPM
NCWC 2150-A 140 ft- 165 It. 29 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L'LNER it a° licable
FROM TO DWNETERI THICKNESS I MATERIAL
Justice Well Drilling Inc 0 188 it. 1 61/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eotherm21 closed-too
SW20-0460 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable a 11 permits(i.e.Counm State.Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSI7E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) tgResidential Water Supply(single) ft. ft. tn.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD 8•AMOUNT
❑ire ation 0 ft. 1 fl- Hole Plu 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 rL 30 R- Easv seal 2 Bags pumped
injection Well: 85 rL 88 D• Easy seal 1 bag Pumped
❑Aquifer Recharge ❑Groundwater Remediation 10.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEM£\TMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary -
❑Geothernal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness willrork is e.gmin size.etc.
❑Gcothernal(Heatin Cooling Return) ❑Other(explain under921 Remarks) 0 it. 46 R- Rock&dirt
4/08/21 46 tL 82 ft- Sand cla uarts
4.Date Well(s)Completed: vvcll ID# 88 ft- 185 e. Granite Quarts
5a.Well Location: ft. ft.
Megan & Wesley Webb ft. rut.
Fac ilitylOHner Name Facility 1D#(if applicable) RECEI
ft. ft.
75 smokey Mt Dr Marion N.0 28752 ft. ft.
Physical Address.City,and Zip 21 REMARKS
McDowell 160900730099
a'
irl
County Parcel Identification No.(PIN) ,e "n I an e'
essing unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 'rtification:
(ifwell field,one IaVlong is sufficient)
35.67386 N -82.004334 `Y CAA; te
gmatareafCertt ed Vein tractor — Da4/08/21
6.Is(are)the well(s): ❑Permanent or ❑Temporary Bm'signing This form.I hereb}'cent ,that the well(s)i,nv(trere)constructed in accordance
ivilh 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standardv and that a
7.Is this a repair to an existing well: ❑Yes or CKNo cagy of this record has been prodded to the well ovner.
/f this is a repair.fill out knouv well construction it torntation and explain the nature of the
repair under#21 remarks section or on the hack of this forn. 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple urlly list all depths ifdifjerent(example-3@?200 and 2C/00) construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,information Processing Unit,
1f tvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In imddition to sending the form to the address in
Rotary construction
24a above, also submit a copy of this 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 SUPPLYService WELLS ONLY: 1636 Mail Se �ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c•For Water Supply&Injection Wells:
Also submit one copy of this foam within 30 days of completion of
13b.Disinfection type: Clorine 730/amounh 8 oZ well construction to the county health'department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Dhrision of water Resources Revised August 2013