GW1-2021-05272_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 100 ft• 115 ft- 4 Ito 4 Gal per hr *******
NCWC 2150-A rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifs licable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 ft. 36 ft• 6 1/8 in. I SDR 211 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
27133 FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. i in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER 11 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
ft. ft. ifi•❑Geothermal(Heating/Cooling Supply) XResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO ATERNL EMPLACEMENT METHOD&AMOUNT
❑hri ation O rt. 2 rt. o e plug 1 Bag Poured
)Von-Water Supply Well: 2 rt. 22 ft. Easy seal 2 Bags pumped
❑Monitoring ❑Recovery
Injection well: 34 ft• 36 ft• Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 ft. Lose Rock& Dirt
4.Date Well 4/29/21s)Completed: Well ID#
16 ft• 465 ft- Granite Quarts
5a.Well Location:
Ron&Julia Thompson C/O Mario Cifaldi
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 'f. '��
1052 Winter Star Rd -
Physical Address,City,and Zip 21.REMARKS
Yancey 073703012814000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
]artitication:
(if well field,one Iat/long is sufficient) 4
35.828101 N -82.271435 W u/ 4/29/21
Signature of Certi Well Co ctor' Date
6.Is(are)the well(s): Wermanent or ❑Temporary Hy signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
with l5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cohstruclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has been provided to the well owner.
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 hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS!
9.Total well depth below land surface: 465 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
13a.Yield(gpm)-0 9`��� Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection typc ClQCIr1P. 73t2% Amount: 8 oZ well construction to the county'health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013