GW1-2021-02744_Well Construction - GW1_20210404

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 �oA+ 155 ft 165 R 75 GPM +
NCWC 2150-A �� '� L`
15.OUTER CASING for multi-cased,rells) ablOR a "icMA RALNC Well Contractor Certification Number FROM TO DIAMETER
Justice Well DrillingIn ,. e'°�`` ��tnt� ft- in•
G' Z 0 150 6 1/8 SDR 21 PVC
Company Name 16.INNER CASING OR T BING geothermal closed-loop)
W20-0297 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in•
List all applicable well permits(i.e.Co nw,Stale,lro•iance.Injection,eta)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTS17.E THICKNESS MATERIAL
in.
❑Agricultural ❑Municipa/Public
❑Geothelmnal(Heating/Cooling Supply) HResidential Water Supply(single) ft. [t. tm•
❑Industrial/Comnmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
❑Irri gation 0 ft. 1 ft• Hole Plug 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft- 100+11• Easv seal 14 bags
Injection Well: 148 fL 150 ft- Hole plug 20 Bag Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery []Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomm%vater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20 DRILHNG LOG attach additionat sheets if necessara`
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hsrdness.soiltrock type. rain size.etc.
❑Geothernmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 130 ft. Rock& dirt
4.Date Well(s)Completed: 3/08/21 Well 1D# 13GL 145 1- Red water & Rock
145 'L 160ti• Granite Quarts
5a.Well Location: ft. ft.
Kelly Parker fL ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
71 Ebenezer Church Rd ,Old Fort N.0
Physical Address,City,and Zip 21.:REMARKS
Mcdowell 07600228552
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rti6cation:
(if well field,one lat/long Is sufficient)
35.642487 N -82.153777 W CAA AA _ 3/08/21
'ignature of Ccr rued Vell tractor r Date
6.is(are)the well(s):XPermanent or ❑Temporary By signing this form, I hereby cerlifi th[iI the xell(s)was(were)constructed in accordance
with 15A AVCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing%veil: ❑Yes or CKNo copy 9fthi.s record has been provided to the well onver.
If this is a repair,fill out known well construction inlornnation and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this pageto 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 nor-iialer supply,cells ONLY with the sane construclion.You can
submit one.fora. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3r 200'and 2@100') construction to the following:
10.Static water level below top of casing: 100 (R•) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: iIn 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: construction to die 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) 75 GPM Method of test: Air 24c.For Water Supply R Injection;Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection t Clorine 73°/amount: 8 oz well construction to the county he'Ith department of the county where
ype:
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013