GW1-2021-06767_Well Construction - GW1_20210809

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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 Justice 14.WATER ZONES
FROM TO DESCRI±P170N
Well Contractor Name 260 ft. 280 ft' 1 CO
NCWC 2150-A 380 ft. 390 ft. 14 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa licable)
FROM TO DIAMETER THICKNESS MATERIAL
.Justice well Drilling, INC 0 fL 84 ft- 6 1/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING fiteothermal elosed-loo
SW20-0518 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
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) NResidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO RIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 2 ft Hole p ug 2 Bags Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery
2 fL 21 ft. Easy seal 1 Bag pumped
Injection Well: 82 IL 84 ft- Hole Plug 1 Bag Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if.a licable
FROM TO MATERIAL 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 sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock in size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 75 fL Red clay
7/20/21 75 ft- 405 ft- Granite Quarts
4.Date Well(s)Completed: Well ID# fL fL
5a.Well Location: ft ft.
Robert Larry& Martha Green C/O Yancy Arrowoo ft. ���
Facility/Owner Name Facility ID#(if applicable) q
ft. ft. � L
_773 Hearthstone Dr. Rutherfordton NC ft. ft r i1alJu ►
Physical Address,City,and Zip 21.REMARKS 11,
Rutherford 1650683 '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• rtification:
(if well field,one lat/long is sufficient) =•�}
35.455701 N -81.957078 w U 7/20/21
Signature of CertifG
Well Co ctor ; Date
6.Is(are)the well(s): XPermanent or ❑Temporary 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
7.Is this a repair to an existing well: ❑Yes or XNo copy of this record has been provided to the well owner.
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. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2Q100') construction to the following:
10.Static water level below top of casing:
100 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 1/8 (in.) 24b.For Infection 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
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12.Well construction method: '7 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(gpm) 15 Method of test:
Air 24c.For Water Supply&Injection Wells
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:Clorine 730/6 Amount: 8 oZ well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Augusf 2613
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