GW1-2021-03935_Well Construction - GW1_20211111

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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#
GW 1-2021-03935
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#:
SW21-0135
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
11/9/2021 20
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Stephen Burgess Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Rutherford
Physical Address* Street Address
1051 Darlington Road
Address Line 2
City State/Province/Region
Rutherfordton NC
Postal/Zip Code Country
28139-8563 us
Latitude* 35.4331559000 Longitude*82.0093590000
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
405 surface?
For multiple wells list all depths if different 54
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
300 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
303 304 20 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 54.00 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 2.00 HOLE PLUG POURED
in feet in feet
2.00 22.00 EASY SEAL PUMPED
in feet in feet
52.00 54.00 HOLE PLUG 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 56.00 soft rock and dirt
in feet in feet
80.00 405.00 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
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* 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*
C 2t-y b fGsGCe
Signature of CertifiedWell Contractor
Submittal Date 11/11/2021