GW1-2021-07559_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
F
1.Well Contractor Information:
Gary Justice Y4.;WA17ERZONES
FROM TO DESCRIPTION
Well Contractor Name 190 h• 200 ft• 5 1/2 G P M
NCWC 2150-A 260 IL 270 ft- 14 1/2 GPM
NC Well Contractor Certification Number 15.OUTER'GASING for multi=cased welts OR LINER if a licable .
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft 96 n 61/8 In. SDR 21 PVC
Company Name 1Cf INNER CASING OR TUBING'. eotbermal closed-loo
FROM TO
SW2-02O0 DIAMETER THICKNESS MA7FRIAr.
2.Well Construction Permit#: 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 I DIAMETER SLOT SIZE TffiCIINESS MATERIAL
in.
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oltrigation 0 fL 1 ft. Hole Plug 1 bag poured
Non-Water Supply Well:
1 & 21+ Easy seal 1 Bag pumped
❑Monitoring ❑Recovery
Injection well: 95 fr. 96 ft- Hole Plug 1 Bag poured
❑Aquifer Recharge ❑Groundwater Remediation A9.SAND/GRAVEL PACK if applicable)
;.
FROM I 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 1. DESCRIPTION color,hardness,soil/rack typt6 grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks). ft ft
4.Date Well(s)Completed: 8/5/21 Well lD# 0 f 89 ft' Dirt ROCK Sand
ft. ft.
5a.Well Location: 89 ft. 305 ft• Granite.Quarts
Jason.McCall Gate 8612 ft. ft.
Facility/Owner Name Facility D>(if applicable) ft. ft.
587 Shoal Creek Trail Nebo N.0 28761 ft. fL
Physical Address,City,and Zip 21.REMARKS
McDowell 6700534443
County Parcel Identification No.(PIN) �n�tt0 CJg
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtirrcad
(if well field,one laUlong is sufficient) 4 1185.5668806 N -81.8731129 W 8/5/21
ignature of CertMed ell tractor Date
6.Is(are)the well(s): 19Permanent or ❑Temporary By signing this form,I hereby cedes 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 KNo 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 thisform. 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: 305 (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2®100) construction to the following:
10.Static water level below top of casing: 160 (ft.) Division of Water iResources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: In additimi to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 20 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 730/9LmDunt• 8 oZ well construction to the county health department of the county where
constructed.