GW1-2021-02746_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justices 14.WATER ZONES @ '
{, -'7,"' FROM TO 1 DESCRIPTION
Well Contractor Name •� G 17511- 1801t- i.1/2 GPM
NCWC 2150-A ��� 1t- 330 1t• 1 '1/2 GPM
NC Well Contractor Certification Number nprli r' 15.OUTER CASING for It'
-eased ivelbi OR LINER Ifool
o lkable
.����A v-n,�iflll FROM TO DWMETER THICKNESS MATERIAL
Justice Well Drilling Inc �,sti�`+����;���� 0 154 "L 1 6 1/8 in. SDR 21 PVC
Company Name 16.INNER CASING OR TllRING oth'trmal closed-too
2.Well Construction Permit#: Y V �F G
S�J� 20-0�t 02 FROM TO DIAMETER THICKNESS MATERIAL
fL ft. I in.
List all applicable ivell permits(i.e.Couny-_State Variance.Injection.etc.)
(t. ft. in.
3.Weil Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTS17Z THICKNESS MATERIAL
❑.Agricultural ❑Municipal/Public It ft. in.
❑Geothermal(Heating/Cooiing Supply) ClResidential Water Supply(single) ft. R, in.
❑fndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOL74T
01n;•ation 0 ft. 1_ rt. Hole Plu 1 Bag poured
Non-Water Supply Weil:
❑Monitoring ❑Recovery 1 It. 30 ft- Easy seal 2 Bags pumped
Injection Well: 150 It' 155 R. Easy seal 1 ba Pumped
❑Aquiter Recharge ❑Groundwater Remedialion 19.SAND/Gftwvl t,PACK III atiollicablel.
❑Ayuifer Storage and Recovery ❑Salinity Barrier FROM 1t. TO f1. MATERIALI EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attachadditional sheets if oecessn
❑Geothemlal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harthieni,oillmkl agrata sire eft.
❑Geothermal fleating Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 46 f1 Rock &dirt
4.Date Well(s)Completed: 4/06/21 well 1D# 46 ft' 95 ft Sand Cla warts
95 "L 149 n- Clay sand lose rock
5a.Well Location: 149 ft. 405 fL Granite Quarts
Terry Miles ft.
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
1329 Mitchell View Dr. Old Fort ft. ft.
Physical Address,City,and Zip
21.REMARKS
McDowell 065700309943
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtificalion:
(ifwell field,one laVlong is sufficient)
35.551300 N -82.183292 W _4/06/21 _
ignatureofCerti led ell tractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary Rv signing this form,I hereby certify that:the well(s)ryas(were)constructed in accordance
with I5A NCAC 0 2C.0100 or 15A N'CAC 02C.0200 lVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or CKNo cape ol'this record has peen provided to the vie//owner.
(f this it a r`.air.fllanl bxnxvr nr!?ronrtrvrlion rr:fmaaafrnn nrd erp?nin for unnae nflhe
repair tinder 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.
];'or multiple byeetion or non-unler.cupply wells ONLY with the same construction,)in can
submit one form. G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells. list all depths ifNfjerenl(example-3@?00'and 2@q 100') construction to the following:
10.Static water level below top of casing: 110 (1t.) Division of Water Resources,Information Processing Unit,
Ifumter level is above casing.use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lniection Wells ONLY: In addition'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: '7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gP ) Method of test:13a.Yield m Air 24c.For Water Supply&Injection Wells:
.._.___._...___...._.._._.............
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Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Clorine 73O/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 sources-Division of Water Resources Revised August 2013
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