GW1-2021-01872_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:
Gary Justice 14.WATER ZONES
FROM TO DESCRIPTION i
Well Contractor Name 280 It- 300 ft- 1/2 GPM
NCWC 2150-A 600 1t• 602 ft• 29 1/2 GPM
NC'Well Contractor Certification Number 15.OUTER CASING fur maltt-eased wells OR LINER f u Jicable
FROM TO DIAMETER TIIICICNESS 1tATER1AL
Justice Well Drilling Inc 0 ft 160 tt 6 1/8 i SDR 21 PVC
Company Name 16,INNER CASING OR TUBING eathermal clowd400 _
SW210032 FROM DI TO AMETER TIiICICNESS MATERIAL
2.Well Construction Permit#: ft. f. in-
List all applicable well permits(l-e.Counn•.Strue.Variance.Injection,etc-.)
ft, I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
,
❑Agricultural ❑Mu nicipaliPublic
❑Geothemial(Heating/Cooling Supply) HResidential Water Supply(single) tt. ft. In.
l
❑InduslriaUCommerctal ❑Residential Water18.GROUTSupply(shared) FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation 0 ft. 1 ft• Hole Plu 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 i`' 30 i`' Easy seal 2 Bags (Dumped
Injection Well: 158 ft• 160 ft Easy seal 1 bag Pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa _
❑Geothemml(Closed Loop) ❑TTacer FROM TO DESCRIPTION color,hardness sollfrock type,11rain sin etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft• Rock& dirt
4.Date Well(s)Completed: 4/14/21 well ID# 80 tt. 140 i Sand clay quarts
14011• 150 ft- White quarts brown quarts
5a.Well Location: 150 ft. 605 ft. Granite Quarts
Thomas E. Roberts
Facility/Owner Name Facility IDa(if applicable) --
ft.
1080 Rockhouse Rd Marion N.C ft. f,. , • ,
Physical Address,City,and Zip 21.REMARKS
McDowell MA 31021
County Parcel Idctuitication No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: rtificatinn: ^1,pi1 to
(if well field,one lal/long is sufficient) 2 D�PJ,I 5 �
35.850814 N -81 .989074 W _ 4/14/21_ _
ignature of Certt tcd ell tractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporay By signing this form,i herehr certift Thal the well(sl use(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that n
7.Is this a repair to an existing well: OYes or HNo copy of this record has been provided to the well newer.
Ifthis is a recmr.fill out knorcn ive11 construction iufrrmation and explain the nature afthe
repair under#21 renmrkc section or on the hack of this form. 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 yells constructed: 1 f construction details. You may also attach additional pages if necessary.
For multiple iajecriart or non-water•.sttpp(y wells ONLY with the same eonstructian,r(la can
submit onefornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdtiple wells list all depths ifdWfereat(example-Aji 100'and 2(d 1()0') construction to the following:
10.Static water level below top or easing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is ahove casing.use••+" 1617 Mail 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 clays 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
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13a.Yield m Air 24c.For Water Supply&Injection�Wells:
(gp )___ o Method of test: Also submit one copy of this Pont within 30 days of completion of
13h.Disinfection type: Clorine 730/amount: 8 oZ well constnction to the county health`department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Dhision of Water Resources Revised August 2011
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