GW1-2021-01835_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
FROM TO DESCRIPTION
Well Contractor Name 100 f t 1 1 5 f- 1/2,__
NCWC 2150-A 550 f'• 555 f- 32 1/21 _
)\�Well Convector Certification Number 15.OUTER CASING for multi-cased x`vclls OR LIVER f d "cable
FIrU�t TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 75 "- 61/81 ':n
' 1 SDR 211 PVC
Company Name 16.INNER CASING OR TUBING edthcrmnl closed400pl
FROM
5890_3 TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: _ _ ft. ft. in.
List all applicable well permits fi.e.Counq.State,Verionce,injection,etc•:)r in.
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 74Residential Water Supply(single)
ft. ft. ia.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT b
FROM TO MLU.RIAL EMPLACEMENT METHOD&,"IOUNT
❑lrri rnti0n 0 rt. 2 ft. Role plug 1 Bag Poured
Non-Water Supply Well: 2 ft. 22 ft. Easy seal 2 Bags pumped
❑Monitoring ❑Recovery
injection Well: 73 " 75 ft Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwatcr Remediation 19.SAND/GRAVEL PACK if applicatile
FROM TO BfATER1A'L EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft.
❑Aquifer Test ❑Stonnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additioriai sheets if neceisai•y
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness,a,ii/mck type, rain size,eft.
❑Geothermal(Heatin*Coolin r Return) ❑Other(explain under 421 Remark.1)_J ft. 70 fL Lose'Rock& Dirt
ft. ft.
4.Date Well(s)Completed: 4/23/21 wen 1D# 70 fl. 565 f. Granite Quarts
5a.Well Location: rL R.
Nicole Solnes N. fL .
Facility/Owner Name Facility ID4(il'applicable) ft ft.
2150 Aragon Trail wilderness Edge lot 22 ft. ft.
Physical Address.City,and Zip 21.REMARKSMAY 1:3:N211
Burke
County Parcel Identification No.(PIN) lit^vr1� 3xlOi1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: fftification:
(if well field,one latllong is sufficient) AA
35.82120 N -81 .884180 w _._._...._.__..._.. u_. " 4/23/21
Signature of Ceni Well Co clop Vale
6.is(are)the well(s): Wermanent or ❑Temporary By signing this jorm, 1 herehp certo.v that the nK116)wt2s(were)catuMucted in accordance
with 15A NC'AC 02C.0100 or ISA NCAC 02C.r1200 Nell Construction Standards and that u
7.is this a repair to an existing well: ❑Yes Or IgNO copy o)'this record has been provided to the well owner.
lfthis is a repair.fell ottt known well construction iufornnatian and explain the nature of dye
repair under#21 remarks section or on the back of this jrrm. You
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 injection at•non-wvtter.cupp/r nwils ONLY with the same roustrucliaa,roll con
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this Iform within 30 days Of completion of well
For multiple wells list all depths if different(example-1(e?200'and 2(n;100') construction to late following:
10.Static water level below top of casing: 60 (ft-) Division of Water Resources,Information Processing Unit,
IJ'nrnter level is abate raring.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wens ONLY: iln,addi6on to sending the form to the address in
Rotary 24a above, also submit a copy of This form within 30 days of completion of well
12.Well construction method: '] 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
4 Air 24c.For Water Supply&Iniection'Wells:
13a.Yield(gpm) `�3 Method of test: _
Also submit one copy of this Porto ivithin 30 days of completion of
13b.Disinfection typeClorine 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