GW1-2021-02100_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells TER 7)
1.Well Contractor Information: ��+T
Gary Justice 14.WATER ZONES
II ll o 2Q21 FROM TO DESCRIPTION
Well Contractor Name 160 ft- 180 ft' 30 GPM
NCWC 2150-A Infi�rlratlQn processing Ur1t ft. ft.
p A'{$ C11�n 15.OUTER CASING for.multi-cased wells OR LINER if a licable
NC Well Contractor Certification Number
FROM TO DIAMETERI TffiCKNESS MATERIAL
Justice Well Drilling Inc 0 ft. 170 ft 61/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal.closed-loo
10987 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 MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. io:I
ft. f. in
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) `
❑industrial/Commercial XResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 H• 1 fL Hole Plug 1 bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft- 21 fL Easv seal 1 Bag pumped
Injection Well: 69 ft. 70 ft. Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if i licsble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. I '
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheetsif necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soWrock rim gminsize,etc
❑Geothermal(Heating/Cool ing Return) ❑Other(explain under#21 Remarks) I h• h•
4.Date Well(s)Completed: 6/21/21 Well ID# 0 ft. 60 fL Dirt ROCI(
60 ft. 225 ft• Granite Quarts
5a.Well Location: ft. ft.
Leevon Mckinney C/O Sweet creek const & ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
759 Dula Rd Spruce pine nc ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mitchell 0798-00-34-3294
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification• e
(if well field,one latAong is sufficient)
35.637994 N -82.04863 W CAA AA 6/21/21
ignature of Cerh ed rell Otractor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this form,I 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: XYes 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: 225 (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@I00) Construction to the following:
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10.Static water level below top of casing: 80 (ft.) Division.of.Water Resources,Information Processing Unit,
If water level is above caring,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
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) 30 G P M 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/amouot• 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