GW1-2022-09220_Well Construction - GW1_20220914

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 90 ft 95 ft• 1 G P M
NCWC 2150-A 185 rt• 200 tt• 84 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FRO
g 0 M ft. 86 rt. DIAMETER6 1/8 in. SIDRE21 PVC L
Justice well Drillin , INC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
226844 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.❑Agricultural ❑Municipal/Public in.
❑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
❑litigation 0 rt. 1 rt. Hole Plug 1 Poured
Non-Water Supply Well: 0 ft. 21 ft. Easy seal 1 Bag pumped
❑Monitoring ❑Recovery
Injection well: 84 ft- 86 ft- Hole Plug 1 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,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft. Dirt ,Rock
4.Date Well(s)Completed: 9/1 4/22 Well ID# 80 ft- 160 ft- Very soft rock
160 IL 185 ft. Granite Quarts
5a.Well Location: 185 rt• 200 ft• Large break
Associated Construction Trades lot 9 200 rt. 245 ft• Granite Quarts
Facility/Owner Name Facility ID#(if applicable)
ft. fit.
175 Hanging Rock Estates lane Banner Elk 2860 rt. ft.
Physical Address,City,and Zip 21.REMARKS
Avery 185811657961 Would not stop giving grit Set punp high
County Parcel Identification No.(PIN) Well blows 30 GPM @ 70'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
36.15101 N - 81 .85580 w 9/14/22
Signature of Ce oed ell tractor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this m,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: 245 (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: 40 (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 85 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