GW1-2021-01833_Well Construction - GW1_20210503

f
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells f
1.Weft Contractor Information:
Gary USt�Ce 14.WATERZONES
J
FROM TO DESCRIPTION
Well Contractor Name . 100 it• 115 n- 3 GPM
NCWC 2150-A 21Oft• 215 ft- 112 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a llcable)
FROM TO DIAMETER MATERIAL THICKNESS
Justice well Drilling, INC 0 ft. 75 ft. 6 118 in. SDR 211 PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loo
30033 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:r_ ft. tL in.
List all applicable well permits(i.e.County.State.Variance.injection•e1c.) ft. f(• in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. tt. in.
❑Agricultural ❑Municipal.Tublic I -+
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft. h. in
❑IndustriallCommercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO M TERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 f" 2 ft. mole Plug 1 Bag Poured
Non-Water Supply Well:
OMonitoring ❑Recovery 2 «. 22 ft. Easy seal 2 Bags pumped
Injection Well: 86 ft- 88 It• Hole Plug 1 bag poured
©Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK ifs licabie
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 attaeh additional sheets If necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I To DESCRIPTION colnr,hardness.snillmck 4Te,grain size,etc
❑Geothermal(Heating/Cooling Relum) ❑Other(explain under 821 Remarks) 0 It. 75 ft. Red clay
4.Date Well(s)Completed. 4/20/21 Well ID# 75 ft, 81 it• Lose Rock& Dirt Red
81 IL 405 it• Granite Quarts
Sa.Well Location: ft. ft.
James Morgan ft. tL
Facility/Owner Name Facility 1134(if applicable) ft. H.
5150 Fish Hatchery Rd Morganton N.0 28655
ft. ft.
Physical Address,City,and Zip 21.REMARKS i '
Burke
County Parcel ldcntitication No.(PIN) Irl#Vni:aitori hrrJCesSin�Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one[attlong is sufficient) 2.9
rtification:
Z.
35.815037 N -81.846950 W A 4/20/21
Signature of Ccrti Wcll Co ctor Date
6.is(are)the well(s): erlDanent or ❑Temporary Br signing this form,I hereby certifi-that the a•ell(v)war/were%cmutrucled in acroMance
with!SA NCAC 02C.01OO or 15A NCAC 02C-02OO fYell Cotesb ucvio»Smnd /s and that a
7.Is this a repair to an existing well: ❑Yes or iKNo copy ufthis record has been provided to the well owner.
If this is a repair,fill out knowrr well construction information and explain the nature of the
repair tinder#21 remarkr section or on the back u/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
submitoneform. e� G SUBMITTALiNSTUCTIONS
9.Total well depth below land surface: 305 (fl•) 24a. For All Wells: Submit this form within 30 clays of completion of well
For multiple wells list all depths if different(example-3(0,1200'and 2(400') construction to the following:
10.Static water level below top of casing:
60 (ft.) Division of Water Resources,Information Processing Unit,
11'"wer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 1/8 (in.) 24b. For Injection Wells ONLY:; in addition to sending the form to the address in
Rotary 24aabove, also submit a copy of;this form within 30 days of completion of well
12.Well construction method: '1 construction to the following:
(i.e.auger,rotary,cable,direct push,ctc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C 1 enter,Raleigh,NC 27699-1636
13a.Yield(gP m) 24c.For Water Supply&Injection Wells.
_ 1 C Method of test: Air 1`7 .... . _...._
Also submit one copy of this lol�m'within 30 days of completion of
13b.Disinfection typeCInrane_ 73%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 Resburces Revised August 2013
I