GW1-2022-06308_Well Construction - GW1_20220713

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 280 fL 340 fL 3 GPM
NCWC 2150-A 438" 439 fL 1 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
g F fL T DIAMETER ID R 21ESS MATERIAL
Justice well Drilling, INC 0 62 u- 6 1/8 in. S
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SW22-0020 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
Lust all applicable well permits(i.e.County,State, Variance,Injection,etc)
fL fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling/Coolin Supply) XResidential Water Supply ft ft. in.
( g g PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 fL Hole Plug 1 Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 0 fL 21 fL Easy seal 1 Bag pumped
Injection Well: 60 fL 62 fL Hole Plug 1 Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock a rain size,etc.
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 u- 50 u- Dirt ,ROck
7/12/22 50 ft. 505 ft. Quarts
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.Patricia Drea&Joan Christiana/Paola Navarrete fL fL
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
367 Eagles Rest Trail Old Fort N.0 28762 fL fL
Physical Address,City,and Zip
21.REMARKS
Mcdowell 06690096576
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)
35.62298 N - 82.12921 W 7/12/22
Signature of Certif Well Co ctor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this form,I hereby certo,that the wells)was (were)constructed in accordance
with 15A NCAC 02C.0100 or•15A NCAC 02C.0200 Well Constrnrction 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.
Ifthis is a repair,fill out known well constrnrction 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mrdtiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 120 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+",1 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
Rotas 24aabove, 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 4 Method of test: Air 24c.For Water Supply&Injection Wells:
�p ) 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