GW1-2021-01042_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD For burned Use ONLY
This farm can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATER ZONES
sROM rU DESCRIPTIONWell C'omewtor Name fl. ft.
NCWC 2150-A 700n 1085n 1 GPM
NC Well Contractor Certification Number IS.OUTER CASING Our addtaxed wear OR LINER H 1111e
FRONT TU DIAMETER TNICKNE MATERIAL
Justice well Drilling, INC o as n• s 1is la DR 21 PVC
Company Name (gyp 16.INNER CASING OR TUBING IRrmd clmed4
SW20-0498 FROaI TO DIAMETER THICKNESS ]UTERIAL
2.WellConstruction Permit R: __
Lrrr all uppli.nMr vrll prnniis ri v.(worn.S'mm. Puri......brjrniwt.en)
ft. It. to.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TU I DIAMETER I SLOTSIZE I THICKNESN MATERLLL
❑Agricultural ❑Municipal Public It. n. io.
R.
06eothetma1111eating;Cooling SuPPIYI Wesidential Water Supply(single) ft. I ft.
❑IndustriaVC'ommercial ❑Residential Wales Supply(shared) IL GROUT
FROM TO N \T RIAL I EMPLACEMENT METHOD&AMOtNT
❑ini ation 0 ft- 2 n. o e p ug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22 n. Easy seal 3 Bags Pumped
Injection Wen: 40 ft- 44 f• Hole Pluq 2 Bags poured
❑Aquifer Recharge OGmundwat r Remediation 19.SAND/GRAVEL PACK IN spollesible)
mom TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft n
OAquifer Test ❑Stormwater Drainage
ft. fl.
❑Ezpenmental Technology ❑Subsidence Control
26.DRILLING LOG fiftlftcla MdldaaY sheb H
OGeothermal(Closed Loup) ❑Tracer mom To DESCRIPTmN tor.x.ra.r...xv.«s ry .ar nr.
❑Geothermal(Hcatin /Conlin Return) OOther(explain under 921 Remarks) o ft- 12 H- Clay Rock
2/05/21 ft. n.
4.Dale W'ell(s)Completed: Well ft. n.
Sa.Well Location: 12 ft• 1085 h- Granite Quarts
Creston Development.t-LC / John Nelson n.
F eility'Owner Name Facilah IDn(if applicable) ft. n. I h'7
151 Creston Dr.Black Mountian N.0 n. ft.
021
Physkal.Address.City.and Zip 21.REMARKS
McDowell 063800821571
County Parcel Idcmificmam No 1PIN1
Sit.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 jlrtincation:
lifwcll field.one lull rng is sutlirienq arw
35.581681 N -82.235338 W' _ 2/05121
Signature of(rrti will('o char Dale
6.Is(are)the w¢n(s): ermanenl or OTemporan' 8, signing This term.I herehr.rent; that Mho uvil(o vnr hart)n,nauv ied in wanrAen..
n lrh!(,{AT',{( n2C' 0190 nr!5.{.NC.{C n.( 02[m)1{'rll(t........ ,,,Sraudant.J...1,hnr a
7.Is this a repair to an existing well: ❑Yes or ®No nyn-of this reror'd has hero pruviJrJ m rhr urll ovmer
11 this u a repair,fall out knoon ueft mnstnalion arlo raNun nnJ rep/ain rhr nature a/rhr
reprir under#2!remarks sec tian or on rhr hark of this form. 23.Site diagram or additional well details:
You may use the back of this page fit provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nnaiple uq-han ar nun-..are,supply veils ONLY avh rhr srmr.analrardun,rue,an
submit orre I..a, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 085 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
F.m mulrip a orl/s tin nil Arprhs i/di//i rem femnrph-3w2tiul er.d?"'10url construction to the following.
10.Static water level below top ofcasing: 714 (ft) Division of Water Resources,Inforlostfon Processing Unit,
ll narcr lend is cheer.using.a.r 1617 Mad Service Center,Raleigh.NC 17699-1617
11.Borehole diameter.
6 (in.) 24b. For loiection Wells ONLY: In addition to sending the Corm to the address in
Rotary 24a about, also submit a copy ul This form within 30 days of completion of well
12.Well construction method: '7 construction to the following:
it.aucer.rotary.cable,daces push cm.l
Division of Water Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(RPm) 1 GPM Method of lest:_ Air 24c.For Water Suwob'&Injection Wells:
p Also submit one copy of this lam) within 30 days of completion of
13b.Disinfection type: CIOrIne 73D�q�mouR1: 8 OZ well construction to the county health department of the county where
constructed.
Fonn GA-I Nonh Carolina Upanment of Emironmenl and]mural Resnunes-Division of W'mer Renmrres Revised August 2011