GW1-2021-03507_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 260 ft. 261 ft• 1'/2 GPM
NCWC 2150-A 640 ft. 650 ft ti2 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER SS if a cable
FROM TO DIAMETER ':TMCKNEMATERIAL
Justice Well Drilling Inc 0 ft 1 110 ft 1 6 V& SDR 21 PVC
Company Name 16.INNER CASING OR TUBING; eotbermat closed-loop)
RE20-0061 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) HResidential Water Supply(single) ft. ft. m•
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 fL Hole IP,lug 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft 21 ft Eas seal 1 Bag pumped
Injection Well: 108 ft. 110 ft. Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SANI)/GRAVEL`PACK'if a 'licab►e
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fL
❑Aquifer Test ❑Stormwater Drainage
ft. ft. i
❑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. 98 ft. ROCK 8t dirt
5/14/21 98 ft- 705 fL Granite Quarts
4.Date Well(s)Completed: Well ID# ft. ft.
SPhl Brunc C/O Higgins Building Gro e*
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2134 Catawba Trail, N= Lot 160 ft. ft. UN X 7 NZI
Physical Address,City,and Zip 21.REMARKS
McDowell 173300880974 ��,f�rrration process
County Parcel Identification No.(PIN) v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtitication:
(if well field,one lat/long is sufficient) 1
35.745465 N -81 .905228 W 5/14/21
ignature of Certr ed r
ll Vitractor Date
6.Is(are)the well(s): XPermanent 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 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 back of this form. 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 construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7�5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@,00'and 2@100') construction to the following:
10.Static water level below top of casing:
100 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (iD.) 24b.For Infection Wells ONLY:! In addition to sending the form to the address in
24a above, also submit a copy off this form within 30 days of completion of well
12.Well construction method: Rotary 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) 3 GPM Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim 1 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.
Form GW-1 North Carolina Department of Environment and Na•sources—Division of water Resources! Revised August 2013