GW1-2022-01347_Well Construction - GW1_20220124

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 DESCRIPTION
Well Contractor Name 175`L 180ft• 1/2 GPM
NCWC 2150-A 320f1• 330 1 1/2 GPM
NC Well Contactor Cenifrcation Number 15.OUTER CASING for multi-eased wells OR LONER if a Gcable)
FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 rt. 154 ft 6 1/8 i° 1 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed4otipj
SW20-0402 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits li.e.County.Stale Variance.hyection.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 +(I
in
❑Geothenmal(Healing!Cooling Supply) XResidential Water Supply(single) in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
❑irrigation 0 ft. 1 ft- Hole!Pluq 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 iL 30 R• Easv seal 2 Bags pumped
lnjection Well: 150 `t• 155- `t• Easy seal 1 bag Pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GkAvEifPACK if applicable)
FROM TO MATERIAL Ei11PLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. 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•soluroch tt e.pnin size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt 46 ft. Rock & dirt
4/06/21 46 " 95 `t• Sand cla uarts
4.Date Well(s)Completed: Well[D#
95 `t• 149 `t- Clay sand lose rock
5a.Well Location: 149 ft- 405 ft'
Granite Quarts
Terry Miles ft. ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft.
1329 Mitchell View Dr. Old Fort
Physical Address,City.and Zip 21.REMARKSMcDowell 065700309943
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(ifwell field.one lat/long is sufficient)
35.551300 N -82.183292 _ _ 4/06/21
'ismetureofCertr red Vell tractor Date
6.is(are)the well(s): ❑Permanent or ❑Temporary 8c signing this form.I herehy certifi,thin the reel/6) was/were)constructed in accordance
With 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or CKNo copy of 1his recortl has been provided to the well ou•rer.
ijthis is a repair.ill out knenfvn well consnvction information and explain the nature of the
repair under#21 remarks section or on the hack 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 ityection at-non-winter supply sells 0A'L 1'with the same construction.You can
submit one farm. 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
Far n u multiple cllc list all depths rjdi/jerent(example-.l[201I and 2100') construction to the following:
10.Static water level below top of casing:
110 (ft.) Division of Water Resources,Information Processing Unit,
ljwater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 246. For lniection 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:
(i.e.auger.rotary,cable,direct posh,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) 2 Method of test: Air 24c.For Water Supply&lniectioi►Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Clorine 730/%mount• 8 OZ well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013