GW1-2021-03506_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 320 ft- 360 ft- 16',GPM
NCWC 2150-A ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 ft. 102 ft. 16 1/$ in. SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: SW20-0437 ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. fL i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
(Heating/Cooling PP y) PP Y g ) ft. ft. in.
❑GeothermalSupply) IffiResidential Water Supply(single)
Filndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MAT RIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 2 ft. Hole plug 1 Bag Poured
Non-Water Supply Well:❑Monitoring ❑Recovery 2 ft 22+ ft. Easy seal 10 Bags pumped
Injection Well: 100 ft- 102 ft- Hole Plug 1 Bag pumped
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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 e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 95 ft. Lose Rock& Dirt
5/22/21 95 ft- 405 ft. Granite Quarts
4..pate Wells)Completed: Well ID# ft. ft. i
5,.Well I.oratinnc ft. ft.
John Chattin ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2058 Oakdale Rd.,Old Fort, NC 28762 ft. ft.
Physical Address,City,and Zip 21.REMARKS
McDowell - 066900682128 infoitnutbri Processing
t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtifcation:
(if well field,one lat/long is sufficient) � � `�
35.628183 N -82.142691 W V%yM,���K 5/22/21
Signature of Certi Well Co4Vctor Date
6.Is(are)the well(s): Wcrmanent or ❑Temporary By 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 HNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks.section or on the back ofthis form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
l or multiple injection or non-water supply wells ONLY with the same construction,you can
SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface: 405 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths it dii ferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 60 (ft,) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 1/8 (in.) 24b. For Infection Wells ONLY: ''In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Rota
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test
Air 24c.For Water Supply&Injection'Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection
typ e Clo pq Amount: 8 oZ well construction to the county health department of the county where
rl7_3 �
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013