GW1-2021-06768_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Justice 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 200ft• 2255 ft' 11/2GPM
N C WC 2150-A 460 ft- 470 ft- 1*1/2
NC Well Contractor Certification Number 15.OUTER CASING for multi-c8sed wells OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft• 1 112 ft- 6 1/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING `eothermal closed-loop)`
FROM TO DIAMETER THICKNESS MATERLAL
2.Well Construction Permit#:
W21-0115 ft• ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 131Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 It. Hole;Plug 1 bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft. 21+ ft- Eas' seal 12 Bags pumped
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.;SAND/GRAVEL PACK if a liceble
FROM TO MATERIAL. I 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 necessa``
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock typc in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
7/15/21 0 ft- 105 ft- Dirt Rock
4.Date Well(s)Completed: Well ID#Wa Va,
105 ft- 505 ft- Granite Quarts
5a.Well Location: ft. ft.
Peak of the Mt campground ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ;-
770 Crutchfield Rd Rutherforton N.0 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Rutherford 1654627
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtitication:
(if well field,one Iat/long is sufficient)
35.507155 N -81.986963 W 7/15/21
ignature of Cerh ed rell tptrad., ` Date
6.Is(are)the well(S): XPermanent or ❑Temporary By signing this form,I hereby cert Jy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Wes or ❑No 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: 505 (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@200'and 2@I00') construction to the following:
10.Static water level below top of casing:
10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: Y
(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
m 13a.Yield
(gp ) 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/amount• 8 oZ well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources` Revised August 2013