GW1-2021-01834_Well Construction - GW1_20210503

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 i•
FROM TO DESCRIPTION
r� tt
Well Contractor Name 70 If- 75 f6 !1�2 GPM
NCWC 2150-A 270 ft- 272 ft- (.29 1/2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wilts AR LINER iI n llcoble
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 fL 1 76 ft• 1 61/8 "J SDR 21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed loo
46570 G i S FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable rove!!permits(i.e.Counn•,State,Variance,lnjertion.etc•)
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
ft. ft. in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) NResidential Water Supply(single)
ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT G
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 1 ft- Holtz Plu 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft. 30 ft• EaS seal 2 Bags pumped
Injection Well: 74 fr• 76 ft• Easy seal 1 bag Pumped
❑Aquifer Recharge ❑Groundwate-Remediation 19.SANDIGRAVEL PACK if applicable)
FROM TO I 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 chiefs it aecesas
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIMION rnlor,hardnes sail/rock tyM grain On,ate.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 46 ft- ROCK& dirt
4/21/21 46 52 fl- � Sand cla uarts
4.Dare Well(s)Completed: Well ID# 52 1t. 285 1t- Granite Quarts
5a.Well Location: rt. ft.
Linda White ft.
Facility/Owner Dame Facility ID4(if applicable)
ft. ft.
5162 Power house Rd , Morganton NC ft. ft.
Physical Address,City,and Zip 21.REMARKS
Burke
County Parcel Identification No.(PIN)
F Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
2 rtificatioD:
(if well field,one[at/long is sufficient)
35.730177 N -81.825963 W
4/21/21
i tureofC'ertated ell tractor F Date
6.Is(are)the well(S): XPermanent or ❑Temporary BY signing this Torn,1 herehl cer tih that fire wellis)was(were)constructed tit accordance
with 15.4 NCAC 02C.0100 or I5A,VCAC 01C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or XNo copv oJ'this record hits been provided to the well owner.
Il'this is a repair•fill out known well construction information and eloplain the nature of the
repair tinder 421 remarks section or on the hack of'thisJbrnt. 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.
For multiple byection or non-water supplr wells ONLY with the same arustruction,you can
submit onejarnr. pC SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this;foam within 30 days of completion of well
For multiple wells list all depths if different(example-Xjrt_200'and 2(c100') construction to the following:
60
10.Static water level below top of casing: (ft.)
Division of Wales Resources,Information Processing Unit,
ff water level is ahnve casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diametelr• 6 (in.) 24b.For Injection 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
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(gp m) 30 Method of test: Air 24c.For Water Supply&Iniection4ells:
_. _
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
Clorine 730/9Lmount: 8 oZ well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural sources--Division of Water Resources • Revised August 2013
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