GW1-2022-04572_Well Construction - GW1_20220504

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 620ft• 650 ft. 2 G P M
NCWC 2150-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
AM TER
IC
g 0 M rt. T96 It. D16 1/8in. TSDRS21 MAPVC
Justice well Drilling, INC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
10207 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
rt. rL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
rt ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water SuPP1Y(single) ft. ft. in.
❑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: 94 rt• 96 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
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 5/04/22yell ID# 0 rt 2 rt Fill
2 ft• 90 ft• Dirt ,Rock
5a.Well Location: rt ft.
Dallas Horney 90 rt 605 ft• Blue Granite,white quarts
Facility/Owner Name Facility ID#(if applicable)
ft. fit.
47 Licklog Rd newland N.0
Physical Address,City,and/ip 21.REMARKS
Avery 181500330095
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)
36.05688 N 82.00081 W � 5/04/22
Signature of CertiJ13 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: 605 (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: 60 (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 1/4 (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 2 Method of test: Air 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