GW1-2021-02752_Well Construction - GW1_20210404

E
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells � °"� k
1.Well Contractor Information:
Gary Justice 14.WATER ZONES
' n<
1 OM TO DESCRIPTION
Well Contractor Name (,'� �•\\ 20 ft- 150 ft- 1/2GPM
NCWC 2150-A ��,��.�,� ft. ft. i
�s rt,
NC Well Contractor Certification Number r, ��1:3' �+ y 15.OUTER CASING(for mulH-eased we16 OR LGVER f a ')Iribk
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 64 6 1/8 1n SDR 21 PVC
Company Name 16.INNER CASING OR TUBING Iaeothe'mal closed-l000l TO DIAMETER THICKNESS
2.Well Construction Permit#:
SW20-0282 R. io. MATERIAL
List all applicable well permits(t.e.County.State,Variance,h jeelimr,etc,.) ft. In
R.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMET R SLOT SIZE 7HICKNFSS MATERIAL
ft. ft.
❑Agricultural ❑Municipal/!'ublic
❑Geothermal(Heating/Cooling Supply) Mikesidential Water Supply(single)
ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 10.GROUT
FROM TO MATERIALj EMPLACEMENT METHOD&AMOUNT
❑itri ation 0 tt. 2 n. Hole plug 1 Bag Poured
Non-Water Supply Well: 2 ft. 22 f. Easy seal 1 BACI Pumped
OMonitoring ❑Recovery
injection Well: 62 IL 64 ft- Hole plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ft tt
❑Experimental Technology ❑Subsidence Control "
20.DRILLING LOG attach additional shuts f(aMefs
aCient erma os `I op) FROM 70 DESCRIP710N color hardoe rofUroek
❑Geothermal Heatin Conlin Return) ❑tither(ex lain under ema s
3/05/21 20 1- 45 Clay!sand lose rock
4.Date Well(s)Completed: Well iD# 45 ft. 59 ft. Rock&dirt
5a.Well Location: 59 ft. 305 ft• Granite Quarts
Ralph& Joyce Boyd
Facility/Owner Name Facility IDN(if applicable) ft. ft.
620 Good Rd Marion N.0 28752 tt.
Physical Address,City,and Zip 11.REMARKS
McDowell 17500559821
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(if well field one InVlong is sufficient) 3/05/21
W
35 879997 N -82.014990 -
Signature o£Certi Well Co ctor Date
6.Is(are)the W¢II(s): Permanent or ❑Temporary By signing this form.i hereby certify that the mwll(r)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DANo copy of this record has been provided to the well ow•trer.
//'this it a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair render kll remarks section or on the back gjthis form.
1 You may use the back of this page to'provide additiionaI well site details or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form.
305 (ft.) 24a. For Well1: Submit this form within 30 days of completion of well
9.Total well depth below land surface:
FOr multiple wells list all depths if dijjerear(example-3@,200'and 2@1001) construction to the following:
40 Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: (ft') 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Rotary
l2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
FOR WATER SUPPLY WELLS ONLY:
e�
Air 24c.For Water Supply&Injection Wells:
13e.Yield(gpm) 1/2 Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection e• Clorine 73°/Q\monnt: 8 oz well construction to the county health department of the county where
tYP • constructed.
Revised August 2013
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources
I
4