GW1-2021-06769_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice F4.WATER ZONES
FROM TO DESCRIPTION,
We]I Contractor Name 280 ft• 300'- 11 GPM: 400'- 410 1GPM
NCWC 2150-A 560ft• 570ft• 11 GPM`: 620-625 1/2GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LTNER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 ft. 76 rL 6 1, i SDR 21 PVC
16.INNER CASING OR TUBING eothermat dosed400
Company Name
SW21-O317 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Lim all applicable well permits(i.e.Comoy,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft• ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial RResidential Water Supply(shared) is.GROUT
FROM I TO TERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 2 ft. o e plug 2 gags Poured
Non-Water Supply Well: ft- 21 ft. Easy seal 1 Bag pumped
❑Monitoring ❑Recovery 2
Injection Well: 130ft• 132 ft, Hole Plug 1 Bag Poured
nAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necem
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Rem!LU 0 ft. 40 ft- Red clay
7/12/21 Well ID# Well # 1 40 ft, 65 ft. Sand and dirt
4.Date Well(s)Completed: 65 ft. 70 ft- Soft rock and dirt
5a.Well Location: 70 ft 705 ft. Granite Quarts
Peak of the Mt-Campground ft. fL
Facility/Owner Name Facility 1134(if applicable) ft. fL
d"
659 Cr&hfield Rd Rutherhr N.0 ft. rt.
Physical Address,City,and Zip 21.REMARKS
Rutherford 1654627
County Parcel Identification No.(PIN) 31a 1 CO r,On
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 rtifcation: v
(if well field,one[at/long is sufficient)
35.506291 . N -81 .984716 W 7/12/21
Signature ofCciliFa
Well Co4Actor Date
6.Is(are)the well(s): BlPermanent or ❑Temporary By signing this form,I hereby cer/tfy 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
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has been provided to file well owner.
'If this is a repair,fill out known well construction information and,explain the nature of the
o
repair under ii11 remarks section or on the hack of this form. Y Site diagram or additional well details:
u may use the back of this page to provide additional well site details or well
1 You
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water.supply wells ONLY with due#ante construction,you can SUBMITTAL INSTUCTIONS
submit one fonn.
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ij water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days 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
r� Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)`�•5 Method of test: Also submit one copy of this form within 30 days of completion of
rlP. 7:�O�g Amount 8 oZ well construction to the county'health:department of the county where
136.Disinfection types rinrl
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wiater Resources Revised August 2013