GW1-2021-03392_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells I
1.Well Contractor Information: i ED
Gary Justice R �fi 14.WATER ZONES
FROM TO DESCRIPTION
''ell Contractor Name U X ") '� 260 tt• 261 ft. 20 G P M
NCWC 2150-A 28$ ft. 289 ft. 25 GPM
irltOrr atiOft I�COCe651rt(1 Vn 15.OUTER CASING for multi-cased wells OR LINER ifa licable
NC Well Contractor Certification Number t^^f /n c+
Justice Well Drilling IncDWR SeCTIOn FROM tt TO ft DIAMETER to THICKNESS MATERIAL
9 0 104 6 T/8 SDR 21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
39360 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.
Oindustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri ation Q ft. 1 ft. Hole Plu 1 Bag poured
Non-WaterMonSupply Well:
UMonitoring ORecovery 1 H- 21 ft. Eas seal 1 Bag pumped
ito
Injection Well: 102 fl• 104 ft- Easy Seal 1 bag poured
[]Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK ifs Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• ft. tt.
❑Aquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed hoop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,givin size,etc.
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks)J 0 ft. 98 ft. Rock&dirt
4.Date Wells)Completed: 5/1 0/21 Well ID#� 98 It. 305 ft. Granite Quarts
tt. ft.
5a.Well Location: ft. ft.
3rett&Mandy Nix C/O Lake James Custom Home ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2216 Obeth Rd Nebo N.0 28761 ft. ft.
F'aysical Address,City,and Zip 21.REMARKS
Burke Lot 85
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds cr decimal degrees: 2 rtification:
(if well field,one lat/long is sufficient)
35.751277 N _-81.904767 W 5/10/21
ignature of Cert)led ell ft
tracto Date
6.Is(are)the weli(s): XPermanent Or OTemporary By signing this form, 1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construchan Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo 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 hack of thisforin. 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 car)
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
I or multiple wells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:' 6 (in.) 24b. For In'ec1 tion Wells ONLY: In addition to sending the form to the address in
Rota�J 24a above, also submit a copy',of this form within 30 days of completion of well
12.Well construction method: '7 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(gpm) 45 GPM Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this f fo'rm within 30 days of completion of
Clorine 730/ 8 oZ well construction to the county Health department of the county where
13b.Disinfection type: amount: constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Watter;Rescurces Revised August 2013