GW1-2021-02459_Well Construction - GW1_20211014

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
G W 1-2021-02459
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Gary Justice [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
Owner Well Contractor
1. Well Contractor Information:
Well Contractor Name NC Well Contractor Certification# Company Name
2.Well Construction Permit#:
SW21-0253
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
10/14/2021 1
(gallons per minute)"

5.Well Location
Facility/Owner Name*
JODY&MANDY CRISP Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
McDowell 1713003568112
Physical Address* Street Address
300 Lakeview Drive
Address Line 2
City State/Province/Region
Marion NC
Postal/Zip Code Country
28752 us
Latitude* 35.4407350000 Longitude*81.5921220000
Decimal degrees Decimal degrees
............................................................................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes o No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
605 surface?
For multiple wells list all depths if different 116
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
60 6 1/8
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
1 13a. Method of test:
If applicable
13b.Disinfection type:* 13b.Amount:
Chlorine 73%
...................................
14.WATER BEARING/FRACTURE ZONES

From To Description
400 480 1/2 gpm
in feet in feet
520 540 1/2 gpm
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
..................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
...............................................................................................
From To Material Emplacment Method&Amount
0.00 1.00 Hole Plug 1 Bag Poured
in feet in feet
1.00 21.00 Easy Seal 1 Bag Pumped
in feet in feet
114.00 116.00 Hole Plug 1 Bag Poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
1.00 80.00 Red Clay
in feet in feet
80.00 110.00 Soft Rock&Dirt
in feet in feet
110.00 605.00 Granite Quartz
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION

* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification* rn�
Signature of Certified Well Contractor
Submittal Date 10/14/2021