GW1-2021-02097_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
1.Well Contractor Information: I
Gary JusticeRECEIVED14.WATER ZONES
FROM TO DESCRIPTION !
Well Contractor Name 1 I O J 2021 75 ft. 76 rt. 1%2G PM
J
NCWC 2150-A U 240 ft• 241 ft• 3 1'�/2 GPM
NC Well Contractor Certification Number 1115^vi'1�,3iOT1 I(�."JCBSSICtg Unit
15.OUTER CASING for multi cased wells OR LINER if a livable
DVVR..ec on FROM TO DIAMETER THICKNESS MATERIAL
Justice Well Drilling Inc 0 ft. 1 63 ft- 1 6 1/8 in. SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-10010)
W21-0244 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permus(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
nindustrial/Commercial XResidential Water Supply(shared) i8.GROUT i s
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑ anon 0 ft. 1 ft. Hole Plu 5 Bagpoured
❑Monitoring ❑Recovery 1 ft- 21 ft- Easy seal 2 Bag pumped
Injection well: 60 ft. 63 ft. Easy seal 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑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)
6/15/21 0 f` 55 ft• Dirt Rock
4.Date Well(s)Completed: Well ID# 55 ft• 305 ft' 'Granite Quarts
5a.Well Location: ft. ft.
Florence Black West
Facility/Owner Name Facility lD#(if applicable) ft. ft.
4001 Sugar Hill Rd Mariom N.0 25752
Physical Address,City,and Zip 21.REMARKS
McDowell 079GO0403659
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 rtification:
(if well field,one]at/long is sufficient)
35.637994 N -82.04863 W 6/15/21
ignature of Certi bed ell tractor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By,signing this form, I hereby certify;Ihal the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction S andardc and that a
7.Is this a repair to an existing well: XYes 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 hack 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.
1 or multiple injection or non-water supply wells ONLY with the saute construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (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 a/00') construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,'Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servicc;Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 4 GPM 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/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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