GW1-2021-07948_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATER ZONES E
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
f
NCWC 2150-A 650ft• 700 ft. 11/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER !THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft• 110 ft. 1 6 1/& in- SDR 21 I PVC
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
'2.Well Construction Permit#: W21-057 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 MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in•
❑Industrial/Commercial XResidential Water Supply(shared) FROM
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
CTlrri ation 0 ft. 1 ft. Hole'Plua 1 bag poured
Non-Water Supply Well: 1 et. 21 ft Easy seal 1 Bag pumped
❑"Monitoring ❑Recovery
Injection Well: 108 ft• 110 ft• Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwatet Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. tt.
7/08/21 0 ft• 105 ft• Dirt Rock
4.Date Well(s)Completed: Well ID# 105 ft• 705 ft. Granite Quarts
5a.Well Location:
Jeffery Bittenbinder
Facility/Owner Name Facility ID#(if applicable) ft. ft. q�
1039 Black Forest/ Lot16
Physical Address,City,and Zip 21.REMARKS
McDowell 173007426 Nut P, I
-it
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification: ON I
(if well field,one lat/long is sufficient)
35.73461 N -81 .9744715 W 7/08/21
ignature of Certs ied ell tractor Date
6.Is(are)the well(s): XPermanent or []Temporary By signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: NYes or . ❑No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-waier supply wells ONLY with the same construction,you can
SUBMITTAL INSTUCTIONS
s-,hmit one form.
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 if different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 60 (ft,) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection 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: y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 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 type: Clorine 730/(Am0unt: 8 OZ well construction to the county health department of the county where
constructed. If
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Revised August 2013
Form GW-I North Carolina Department of Environment and Natural Resources—Division of water Resources