GW1-2021-02099_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: I
Gary Justice � ,tl� 14.WATER ZONES
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FROM TO DESCRIPTION
Well Contractor Name 360ft- 380 ft• 1/2GPM
0 � 2021
NCWC 2150-A JUL 390ft 395 ft 10'1/2 GPM
NC Well Contractor Certification Number 1�gG1m,3�fOC1 nCOLB�SICig V131Z 1FSROOUTER CASING for muD'ia�s wRells O L RR SS a I,MATERIAL
Justice well Drilling, IN8 D\f,RS�V�'cn 0 fL 66 fL 16 1/8 SDR 21 PVC
Company Name 16.INNER CASING.OR'TUBING eothermiddosed-loo
10988 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
It. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
MAgricultural ❑MunicipaMblic
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It. 2 ft Hole plug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery
2 ft. 22+ ft. Easy seal 1 bag pumped
Injection Well: 65 ft- 66 IL Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa"`licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. k.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed loop) []Tracer FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 f• 50 It- Lose Rock& Dirt
4.Date Well(s)Completed: 6/21/21 well ID# 50 IL 60 IL Soft rock and dirt
C/O Sweet creek const 60 fw 445 fL Granite Quarts
5a.Well Location: ft, ft,
Sean Smith&Edward Giddens ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
765 Dale Rd Spruce Pine N.0
Physical Address,City,and Zip 21.REMARKS
Mitchell 0798-00-27-6875
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ]artification: k
(if well field,one lat/long is sufficient) f
35.8773008 N -82.064061 W CA^4 6/21/21
Signature of Cerfi Well Co69ctor Date
6.Is(are)the well(s): XPermanent or 1ffiTemporary By signing this form,1 hereby certify that the wells)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 XNo copy of this record has been provided to the well owner.
ff 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: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200'and 2@100') construction to the following: i
10.Static water level below top of casing:
100
(ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'enter,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
Rotate 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 20 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 typeClorine 730/'g 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
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