GW1-2021-02466_Well Construction - GW1_20211014

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
G W 1-2021-02466
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Gary Dean Justice [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2150 A GARY JUSTICE JUSTICE WELL DRILLING, INC.
2.Well Construction Permit#:
SW21-0350
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
10/14/2021 12
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Brian McKinney Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
McDowell 079200409301
Physical Address* Street Address
1423 US 70 West, Marion, NC 28752
Address Line 2
City State/Province/Region
Marion NC
Postal/Zip Code Country
28752 United States
Latitude* 35.4134120000 Long itude*82.0300390000
Decimal degrees Decimal degrees
................................................................................................................................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
305 surface?
For multiple wells list all depths if different 57
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
40 6 1/8
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
12 13a. Method of test:
If applicable Air
13b.Disinfection type:* 13b.Amount:
Chlorine 73%
14.WATER BEARING/FRACTURE ZONES

From To Description
180 185 Less than 1/2 gpm
in feet in feet
240 260 11.5 gpm
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
..................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
...............................................................................................
From To Material Emplacment Method&Amount
0.00 2.00 Hole Plug 1bags poured
in feet in feet
2.00 21.00 Easy Seal 1 Bags Pumped
in feet in feet
560.00 570.00 Hole Plug 1 Bag Poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 19.00 Gravel&Sand
in feet in feet
19.00 50.00 Rock&Dirt
in feet in feet
50.00 305.00 Granite Quartz
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION

* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
* XU
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Signature of Certified Well Contractor
Submittal Date 10/14/2021