GW1-2021-02098_Well Construction - GW1_20210706

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
I r
7 FROM TO DESCRIPTION
Well Contractor Name RF `;I 140 ft. 160 ft. 20°GPM
NCWC 2150-A
NC Well Contractor Certification Number JUL 0 2�21 15.OUTER CASING for multi-cased wells OR LINER if a livable
U�',� FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC �rot;r✓ si1i9 0 ft. 85 ft' 6 1�8 in. SDR 21 PVC
Company Name " DL"� Se 0uul, 16.INNER CASING OR TUBING(geothermal dosed-loop)
10066 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
3AAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) rt. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 2 ft. o e p ug 1 Bag Poured
Non-Water Supply Well:❑Monitoring ❑Recovery 2 ft. 22+ ft. Easy seal 4 bag pumped
Injection well: 84 ft. 85 ft. Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
nAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft.
❑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) 0 ft. 50 ft. Lose Rock& Dirt
4.Date Wells)Completed: 6/23/21 Well ID# 50 ft• 79 ft• Soft rock and dirt
79 ft• 185 ft• Granite Quarts
.5a.Well Location:
Mark Schendell C/O Paul @App Builders
Facility/Owner Name Facility ID#(if applicable)
214 Kantagree dr Bakersville N.0 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mitchell 0886-00-21-6573
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• rtification: `
(if well field,one]at/long is sufficient) � � I`�u
36.075724 N -82.102269 W 6/23/21
Signature of Certi Well Co ctor Date
6.Is(are)the well(s): Ir9Permanent or IffiTemporary By.signing this form, 1 hereby certify that the well(T)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: Oyes or XNo copy ofthis 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 921 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 injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/ls list all depths ifdierem(example-3@200'and 2@100') construction to the following: i
I
10.Static water level below top of casing: 60 (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 1/8 (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: '7 construction to the following: I
(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(;lorlrle 73"�9 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 WateiI Resources Revised August 2013
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