GW1-2021-02519_Well Construction - GW1_20211019

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NORTH CAROLINA
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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 1-2021-02519
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Gary 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#:
W 15-0046
JMB1422
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

10/18/2021 20
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Terry Gour Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
McDowell 0773-0016-0474
Physical Address* Street Address
198 Locust Cove Rd
Address Line 2
City State/Province/Region
Marion NC
Postal/Zip Code Country
28752-9221 US
Latitude* 35.7329000000 Longitude*-82.1303048000
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
225 surface?
For multiple wells list all depths if different 50
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
20 6.13
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)
20 13a.Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
Chlorine 8 OZ

14.WATER BEARING/FRACTURE ZONES
From To Description
85 150
in feet in feet
180 200 18 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 21.00 10.00 SCH 40 STEEL
in feet in feet in inches
0.00 50.00 6.13 SDR 21 PVC
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 1.00 HOLE PLUG 1 BAG POURED
in feet in feet
1.00 50.00 EASY SEAL 4 BAGS PUMPED
in feet in feet
48.00 50.00 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 20.00 SAND LOSE GRAVEL
in feet in feet
20.00 40.00 LOSE ROCK DIRT
in feet in feet
40.00 225.00 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*
fIJYTICE
Signature of Certified Well Contractor
Submittal Date 10/19/2021