GW1-2021-02096_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Gary Justice q ( 14.WATER ZONES !
_6"� I��y9 FROM TO DESCRIPTION
We]I Contractor Name ��"� ft• 310 ft• 5 GPM
NCWC 2150-A ��� p �, 2�21 390 ft• 400 ft. 25 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weus OR LINER if a licable
Justice well Drilling, INC InS�rl"ail°"Pr.� ,an g Uni FROM ft. Tt73 ft DIAMETER to TSDR 21 MATERIAL
PVC
g�, B Se Y 6 1/8
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
W21-0268 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
?,Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.MAgricultural ❑Municipal/Public in!
ft. tt. in:
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single)❑Industrial/Commercial RResidential Water Supply(shared) 18.GROUT I
FROM I TO M T RIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 tt. 2 ft. o e�Plug 1 Bag Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery
2 ft. 22+ ft. Easy seal 10 Bags pumped
Injection Well: 70 ft. 73 ft. Hole Plug 1 Bag pumped
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control `
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 65 ft. Lose Rock& Dirt
6/04/21 65 ft• 405 ft Granite Quarts
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Wesley Sleight
Facility/Owner Name Facility ID#(if applicable) ft. ft.
163 Woody Farm Dr. Marion N.0 28752
Physical Address,City,and Zip 21.REMARKS
' McDowell 077100945659
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(if well field,one IatAong is sufficient)
35.675599 N -82.099417 W 4 6/05/21
Signature of Certi Well Co4gctor E Date
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6.Is(are)the well(s): l�Permanent or ❑Temporary 15
By signing this farm, I hereby certify that the wells)was(were)constructed in accordance
with 1 SA 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 ®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 ofthi.s 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
suhnin oneform. 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
For multiple wells list all depths ifdii ferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
if water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 1/8 (in.) 24b. For Infection 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: '1 construction to the following: t
(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 ) 30 Method of test: Air 24c.For Water Supply&Injection Wellsi
Also submit one copy of this form within 30 days of completion of
13b.Disinfection typeInsnA MOO i O9 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
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