GW1-2021-01754_Well Construction - GW1_20210414

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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: q
Gary Justice 14.WATER ZONES
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A i _ FROM TO DESCRIPTIOT
Well Contractor Name � A �O ` 80 ft' 8J ft- 12 GPM
NCWC 2150-A P� "i �,r�c���`�� 96 tL 98 13 GPM
NC Well Contractor Certification Number 1. ��� A 15.OUTER CASING for tnulhtssed'tveJls'Olt Ll`ER rf a " icable
� ,��, J J�,O FROM fL TO n DIAat9 in, THICRA•ESS MATERIAL
Justice well Drilling, INC ,:-�,,,,� 0 74 6 SCH 40 1 Steel
Cnmpatty Name 16;INNER CASING OR TUBiNCI t titheim'al tlosed-looril
08810 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. H. in.
List all applicable well pennits(i.e.County,State,Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 1�:SCREEN
N'atcr Supply Well: FRODI ' nin.
SLOTSIZE THICI4NESS MATERIAL
❑Geothermal(Heating/CoolingSupply) NResidential Water Supply ft. ft.
PP Y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) �o ROUT To fA RIAL EMPLACEMENT METHOD 8 AMOUNT
❑lrri ation 0 rt. 2 ft. Holeplug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft. 22 ft. Easyt seal 2 Bags pumped
Injection Well: ft. R.
BAgaiferRecharge 170roundwaterRemediation 19.,SAND/GRAVEUTAG-KZfil 1ica fit 6V6 5L�:,
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier p. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach addit(oval sheets'if.necessary
❑Geothermal(Closed Loop) ❑Tracer FRoaf TO DESCRIPTION colon hardness snit/rack t c, rain s,erc.
eo terms ea m Asia ttrA er _21 Remarks) 0 ft. 40 ft- Black dirt clayAa
4.Date Well(s)Completed: 3/30/21 Well ID# O �-m-�1' 1 rOC sand
68 fL 105 ft- Black and Blue Geanite Quarts
5a.Well Location: ft. R.
Robert T. Boland ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
73 Meadow Creek Ln Bakersville, 28705 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mitchell Casein Hammer used
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:(ifwell field,one lat/long is sufficient) '36.094161 N -82-098618 �� Eification4 u44-ce 3/30/21
Signature of Certi Well Cotpetor j Date
6.Is(are)the we0(s): ermanent or ❑Temporary
Yr B},signing this font, I hereby ceno,that the wells)teas(were)constructed in accordance
with ISA A'CAC 02C.0100 or 15A ACAC 02C.0200 1Vell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or NNo cope of this record has been provided to the well owner.
#'this it a repair,fill out known hell construction in/bnnation and e_iplain the nature ofthe
repair under#21 remarks section or on the back ofthis forni. 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 ntuhiple ii jection or non-wvter supple'ivells ONLY with the same construction,.% ucan
submit one forte SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For ntuhiple ive/ls list all depths if different(example-305-200'and 2CI00) construction to the fallowing:
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10.Static water level below top of casing: 15 (it,) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:5 1/2 (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: ry 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
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13a.Yield(gpm) 25 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this font within',30 days of completion of
13b.Disinfection type>Clarine 730 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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