GW1-2021-04210_Well Construction - GW1_20211117

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
GW 1-2021-04210
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:
Certiticate# Cert Level First Name Last Name Company Name
2150 A GARY JUSTICE JUSTICE WELL DRILLING, INC.
2.Well Construction Permit#:
W10100620
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
11/17/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
JAMES WALSH Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Burke 2705067978
Physical Address* Street Address
1070 Belvidere Lane
Address Line 2
city State/Province/Region
Morganton NC
Postal/Zip Code Country
28655-8047 US
Latitude* 35.7999499000 Longitude*-81.6957538000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes 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.)
505 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
50 6.13
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) 13a.Method of test:
If applicable
13b. Disinfection type:* 13b.Amount:*
CHLORINE 8 OZ
......................
14.WATER BEARING/FRACTURE ZONES
From To Description

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
0.00 505.00 EASY SEAL pumped 26 bags
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.)
in feet in feet
21. Remarks
Exsisting well. Pea gravel in bottom 300'casing was left in.9'of PVC was removed.
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*
C 2' ( b , r�sGce
Signature of Certified Well Contractor
Submittal Date 11/17/2021