GW1-2021-01045_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD For tire rnal Lse ONLY
'Phis form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice F WATER ZONES
FROM TO DESCTHPr10N
Well Contmemr Name 190 ft 200
NCWC 2150-A 350h- 355 «• 58 GPM
NC'Well Cunhamar C'eniFcation Number FROM TO IS.OUTER CASING for of wds OR LNER If bar
DIAMEIER THICKNESS MATERIAL
Justice well Drilling, INC 0 n. 84 ft. 61/8 i•' SDR 21 PV
Company Name 16.INNER CASING OR TUBING harm to 4
FROM TO DIAMETER THICKNESa MATERIAL
n.
� 2.Well Construction Permit#: 10807 to
__ -
Lioallappluahfewellpermas&,a Coanrv..Starr.tbri,nt e,hoer nun,t1, ft. ft.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SILE THWJAN MN MATERIAL
Water Supply Well: O, R. or
❑A riculluod ❑MmicipalTublie
g b.
OGeothemod(Heating/C'.00ling Supply) ❑Residential Water Supply(single) ---
❑ImlustriaU 1&GROUT Commercial MResldentlal Water Supply(Shared) FROM TO Mk RIAL EMPLACEMENTME1HODd AMOUNT
❑hri anon 0 rL 2 R. o e p ug 1 Bag Poured
Noo-Water Supply Well: 2 rL 22 n. Easy seal 1 Baa Pumped
OMonitoring ❑RLroovery Injection Well:
: 82 84 R. HOIe plun 1 bag our
❑Groundwater Remediatiun 19.SAND/GRAVEL PACK Ra EMPIACEdteNr METHOD
�Ayuifer Recharge mom TO MATERIAL
ElAquifer Storage and Recovery ❑Salinity Barrier f. R.
OAyuifer Test uSmrmwater Drainage ft n
OBEperimental Technology OSubsidence Control 20.DRILLING LOC attach adNtimdahren Baeen
cGeothennel(closed Loop) ❑Tracer TRost ro DESCRIPTION 1mbr.hmdawi lVOak IM,and.+ae rR.
❑Geothermal(fleatin dCasr Return) 00ther(explain under 021 Remarks) 0 IL 60 D. Clay Rock
3/2/21 60 78 fL Clay sand lose rock
4.Date WNI(c)Completed: Well ft. n.
Sm.Well Location: 78 IL 365 «• Granite Quarts
Lonnie Speight fL
Facility/OvemrNmre facility lUa Ufupp6aable) ft. ft.
13 Turtle Ridge In Spruce Pine N.0 R.
Physical Address,City,and Zip 21.REMARKS —_
Mitchell --
Cwnly Parcel Idc.ufu,auun N. (11IN) —
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 2�rtificalion: Q aRa
(if well field one WAD'%is sufficient)
�5 885893 N -82.043520 W 3/2/21
Signal rc f(eM WellC for Date
6.Is(are)the well(s): permanent or ❑Temporary B vA I A d / m,1/ ehl of rh r.... ur110, w I r r srr r J , .dame
uirh 15.4 ACAC 02C.0100 nr 154 VCAC 02( 0200 01 ll C Iradio,Suindrds and 1hm a
7.Is ibis a repair to an eaistiag well: 0Yes or ®No a,pv n/this record has been provided ro rhr nrd mnrrr.
lJrhi..is,rrpaicall nut knomn.rh mn.nrarrh...0ljolo oion,o..nplmn rhr n„me 111%" 7,3•Site diagram or additional well details:
retmir ender all.rm,rkv rrrno-o,an the hock ofI/u,form. You may use the back of this page to provide additional well site details or well
S.Number of wens constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple hgeotion ar nno-uurrr saprb, ,ell.,ONLY uirh the sameransiruninx.rnu rnn SUBMITTAL INSTUCTIONS
submlr one Jrwm-
365 (ft) 24n. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface:
For mulnpleurlGrlln u0 drprks lJdgjnenr(emmplr-3:ii_'tNt'aml'm lnu'I consWchon to the following.
10.Static water level below top of casing: 120 (ft) Division of Water Resources,Information Processing Unit,
1617 Mad Service Center,Raleigh,NC 27699-1617
1f'uo'lrve(e,hoverushrg.um
11.Borehole diameter: 6 (in.) 24b.For 1 'e lion ONLY: In addition to sending the form to the address e
Rotary 14.above, also submit mil a copy of This form within 30 days of completion of well
12.Well construction method:
conenuetion to the following:
(i c.auger erwry. he,direct push.em.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
[13bRyD:i
RSUPPLYWELLS ONLY:wAirtic F W t r Supply&Injection Wellspm) VO Method of test e Also submit one copy of this form within 30 days of completion of
Clorine 73`/o mDDnt: 8 �Z well construction to the county health department of the county where
ctom type: cunstructtxl.
Revised Au gust 2013
Form GW-I Nonh Carolina Depanmcm of fnvironmcnt and Nmurel Rcsouncs Division of Water Resources Su