GW1-2021-02095_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD
oiWMWr Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
r ,
Gary Justice 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 770 ft. 845 ft. 6 G P M
NCWC 2150-A 0 2021 ft. ft j
JUL
NC Well Contractor Certification Number tton 15.OUTER CASING for multi-casedlwells ORLNR
To DIAMETER TMM f a GMp,ace,singUBit s
Justice Well DrillingIri
RAAI
OLt,R Sed'011 0 ft• 104 ft• 1 6 1/8 in- SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
W21-0124 FROM TO DIAMETER THICK NESS MATERIAL
2.Well Construction Permit#: fL ft. in.List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): -17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipat/Public ft i
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft ft m'j
❑Lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑kfi ation 0 ft. 1 ft- Hole Plug 1 Bag poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft. 21 ft• Easv seal 1 Bag pumped
,Injection well: 102 ft- 1041L Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if,a plieiible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft. �
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock a in size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 94 ft. Rock&dirt
5/24/21 94 ft• 845 fL Granite Quarts
4.Date Well(s)Completed: WeII ID# ft ft.
5a.Well Location: ft. ft.
Harold & Katherine Walker
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1792 Tater Town Loop Nebo N.0 28761
Physical Address,City,and Zip 21.REMARKS
McDowell 163900814110 Corrected to show updated static water level
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification
(if well field,one lat/long is sufficient)
35.614459 N -81 .898000 W 6/30/21
ignature of Certi ed PkH Utractor Date
6.Is(are)the well(s): 191'ermanent 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 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 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 satire construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 845 (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@100) construction to the following:
10.Static water level below top of casing:_ ± (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 (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: 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
r
13a.Yield(gpm) 6 GPM Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form i 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
,