GW1-2021-06762_Well Construction - GW1_20211203

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 160 ft. 170 ft. 1/2G P M
NCWC 2150-A 315 ft. 320 IL 59 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 ft. 106 ft. 6 1/8 in SDR 211 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SW21-0397 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS x MATERIAL
rt. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) ®Residential Water Supply(single) ft. ft. in.
( S/ g PP Y) PP Y( g )
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 1 It. Hole Plug Poured
Non-Water Supply Well: 1 ft. 22 It. Easy seal Pumped
❑Monitoring ❑Recovery
Injection Well: 104 ft. 106 ft. Hole Plug Poured
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Storage and Recovery El Salinity Barrier 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) ft. ft.
4.Date Well(s)Completed: 1 2/02/21Well ID# 0 rt. 100 ". Rock & dirt
100 IL 345 ft. Granite Quarts
5a.Well Location: ft. ft.
Breckenridge Homes Inc ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. fit.
325 Larkhaven Dr. Nebo N.0 28762 ft. ft.
Physical Address,City,and Zip 21.REMARKS
McDowell 172200099971
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(if well field,one lat/long is sufficient)
3574941 N -81 .96230 W 12/02/21
Signature of CcrtiJJ3 Well Co ctor Date
6.Is(are)the well(s): XPermanent or ❑Temporary 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
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 back 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 120 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 m 60 GPM Method of test: Stand 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Clorine Amount: 73% 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