GW1-2021-02693_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.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 250 ft- 260 ft. 6 GPM
NCWC 2150-A 320 fL 340 ft• 24 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER.if a licable
FROM TO DIAMETER THICKNESS MATERUL
Justice Well Drilling Inc 0 fL 50 fL 6 1/18 In- I SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
Agricultural FROM TO DIAMETER THICKNESS MATERLkL
2.Well Construction Permit#: g ft. 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
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIMSS MATERUL
ft. ft. in.
MAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft- 1 ft Hole'Pluq 1 bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 fL 21 ft Easyseal 2 bags pumped
Injection well: 48 ft. 50 ft. Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERLIL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock in she,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 7/01/21 well ID# 0 ft- 45 fL Dirt Rock
45 ft- 365 ft- Granite Quarts
5a.Well Location: fL fL
Avery Farms C/O Avery Weigh Still ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
615 Avery Lane Newland N.0 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Avery unit
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(if well field,one lattlong is sufficient)
36.040846 N —82.014624 W 7/01/21
ignature of Cerb ed rell tractor; Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this form,1 hereby cenify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.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: 365 (fL) 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:
15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicejCenter,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotate 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: '7 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 GPM 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/amDunt• 8 oZ well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013