GW1-2021-03514_Well Construction - GW1_20210607

I .
I "
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: l
Gary Justice 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 170 fL 171 ft- 5 GPM":
NCWC 2150-A 260 fL 262 f=• 20 GPM
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. 48 ft 6 1/8 i i SDR 211 PVC
Company Name 16.INNER CASING OR TUBING etithermal closed-loop
10947 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. 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) XResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MAT RIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fl' 2 ft. Hole p ug 2 Bags Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 2 ft- 22 ft. Easy seal 1 Bag pumped
Injection well: 46 ft. 48 ft. Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL 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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock a rain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O fit. 40 ft. Lose!Rock& Dirt
4.Date Well(s)Completed: Well ID#
5/07/21 40 ft. 305 ft. Granite Quarts
ft. rt.
5a.Well Location: ft. ft.
David & Melissa Martin ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Shangrila Trail Lot 4
rL ft. 1pl.. , ti011 prC--t?sSIRO UIll
Physical Address,City,and Zip 21.REMARKSClt
Mitchell 0798-00-95-8015
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(ifwell field,one lat/long is sufficient)
35.867919 N -82.037014 W ? 5/07/21
Signature of Certi Well Co .ctor ! Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A AtCAC 02C.0100 or 15A NCAC C2C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No 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 921 remarks section or on the hack 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 construction,you can
submit oneform. 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
For multiple wells list all depths!different(example-3@200'and 2@100') construction to the following:
i
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 1/8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Rotas 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: y 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) 25 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 typeCindne 73% Amount: 8 oz well construction to the county health department of the county where
constructed. `
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
,