GW1-2021-03502_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 770 ft• 845 ft- 6,GPM,
NCWC 2150-A ft. ft. i ;
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if o 6cable
FROM TO DIAMETERTHICKNESS MATERIAL
Justice Well Drilling Inc 0 e. 1 104 ft- 1 6 1/81in :SDR 21 I PVC
Company Name 16.INNER CASING OR TUBING eother at dosed-loop)
W21-01 24 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: k I
in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
in.
3.Well Use(check well use): 17.SCREEN ! 4
Water Supply Well: FROM TO DIAMETEW SLOT SIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. 1O'i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑]rri ation 0 ft. 1 ft. Hole hug 1 Bag poured
Non-Water Supply Well:
1 t` 21 f` Eas 'seal 1 Bag pumped
❑Monitoring ❑Recovery
Injection well: 102 ft. 104ft• Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barr;er ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑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. 94 ft. Rock & dirt
4.Date Well(s)Completed: 5/24/21 Well ID# 94 fL 845 rt. Granite Quarts
rt. ft.
5a.Well Location: ft. ft.
Harold & katherine Walker ft. ft. s,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1792 Tater Town Loop 4ebo N.0 28761
_ rt. rt.
Physical Address,City,and Zip 21.REMARKS
McDowell 163900814110 processing unit
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(if well field,one]at/long is sufficient)
35.614459 N -81 .898000 W 5/24/21
ignature of Cen hed ell tractor Date
6.is(are)the well(s): $11'ermanent or NTemporary Hy signing this form,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 XNo copy of this record has been provided to the well owner.
Iflhis is a repair,fill out known well construction information and explain the nature ofthe
repair under?t21 remarks section or an the back ofthis farm. 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 oneform. SUBMITTAL INSTUCTIONS
S.Total well depth below land surface: 845 (ft.) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 200'and 2 a 100') construction to the following: I
10.Static water level below top of casing: 60 (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"1 " 1617 Mail Service Center,Raleigh,NC 27699-1617
k
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: in addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
r
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
m 13a.Yield
(gP ) 6 GPM Method of test: Air 24c.For Water Supply&injectionlWells:
h
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
Clorine 730/amount: 8 oZ well construction to the county health department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i ',