GW1-2021-01797_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD For Internal Use ONLY:
T7lis form can be used for single or multiple wells
1.Weill Contractor Information:
Gary Justice 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name pv 90 ". 95 tt 2 GPM
NCWC 2150-A `' 180ft• 1850 8 GPM
202� 15.OUTER CASING for multi-cased we0s OR LLVER f e licabit NCWeIIContradorCenifcationNumber b=
Justice Well Drilling Inc �� FROM TO DIAMETER THICKNESS 11tnTER1AL
P t).,Xt f'• 20 I• 10 1°• SCH 40 Steel
Company Nome f'31 16.INNER CASING OR TUBING faeotherttnI closed-lo
FROM TO DIAMETER THICKNESS MATERIAL
10054 _ ,,:;; ° „ °°`.°'' 0 k• 74 s v8 i°-
2.Well Construction Permit#: � q ��� SDR 21 PVC
List all applicable uell permits(i.e.Counts.State.1•'uriaderl hyecliotN'A )
3.Well Use(check well use): 17.SCREEN
Water SupplyWelL•_ -_ _ _ — FROM To DIAMETER swTSIZE THICL•NEKS- _MATERiA1 --
❑Agricullural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. k. in:
❑lndustriat/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOLWT
❑Irri ration 0 ft. 1 ft• Hole Plug
Non-Water Supply Well: 1 Bagoured
1 ft- 30 ° Easy sea c
l 2 Ba s Ped
❑Monitoring ❑Recovery pump
injection Well: 70 11• 74 n- Hole PlUg 1 bag Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL EMPLACEMENT METHOD
fL
❑Aquiter Test ❑Stornwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional 1111c"If necessary)❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hi rdne>,a,sotltm r.rk tv sere etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft- Rock & dirt
4.Date Well(s)Completed: 4/01/21 well ID# 80 ft• 95 ft ; Lose Rock
95 It- itt ft- Soft; Granite Quarts
5a.Well Location: ft. &
David Maloney fL ft.
Facility/OxtncrName Facility ID#(ifnpplicable) ft. ft.
14 Snyder Rd Bakersville N.0 ft. ft.
Physical Address.City,and Zip 21.REMARKS
Mitchell :0884=00-80-0583
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathung is sufficient) 1 rtification:
N -82-085614
36.022180 �,, 4/01/21
ignatun:ofCem tcd ell tractor', Date
6.Is(are)the well(s): ❑Permanent or ❑Temporar✓
Br signing this_form,1 herrbv c•errijv That the nett/sj uxzs(tvere)cotstrccc•red in nrcnrdancr
with 15A NCAC 0117.0100 or 15A NCAC 02C.0200 lYell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has heen provided to the urll oicner.
#'this is a repair,fill nut knotin ivell consttrtclion info ntatinn and explain the nature of the
repair finder#21 remarks section or on the hack nfthis form. 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 if necessary.
For multiple h#ection or non-tvater supply uells ONLY with the some construction,pnu can
snhmitmreform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft•) 14a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200 and 2rg100) construction to the following:
i
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
!f water level is ahoy casing.tore '+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: in addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form 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
13s.Yield(gpm) 10 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 type: Clorine 730/%mount• 8 oZ well construction to the county health department of the county where
constructed.
j,
Form GW-1 North Carolina Department of Environment and Katttml Resources-Division of Watcr Resources Revised August 2013