GW1-2021-02111_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.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 670 ft 675 ft 18 G P M
NCWC 2150-A ft. ft.
NC Well Contractor Cerdification Number 15.OUTER CASING for multi-cased wells OR LINER if a icable
FROM TO DIAMETER THICKNESS MATERIAL
Justice well Drilling, INC 0 fL 56 ff• 61/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
763455 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 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
ft. ft.
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) BlResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO RIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 2 fL O e Pug 1 BagPoured
Non-Water Supply Well:❑Monitoring ❑Recovery 2 ft- 22+ ft. Easy seal 4 bag pumped
Injection Well: 54 ft• 56 fL Hole Plug 1 bag poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier ft. TO MATERIAL EMPLACEMENT METHODft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Imp) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain sin,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 421 Remarks) J 0 ft- 50 ft- Lose Rock& Dirt
6/30/21 50 fL 705 fL Granite Quarts
4.Date Wells)Completed: Well ID# fL fL
Sa.Well location: fL fL
Kenney Goodman C /O Alex Johnson fL fL N
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
628 Cranberry View Dr, Newland N.0 28657 ft. fL JUL U u 2021
Physical Address,City,and Zip 21.REMARKS
Avery 1818 0093 5843 o-ura ton Processing unl
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. rtification:
(if well field,one lat/long is sufficient) r
36.075724 N -82.102269 W O 6/30/21
Signature of Cerfilt Well Co ctor rJ Date
6.Is(are)the well(s): XPermanent 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 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#11 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 same eonsbaedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 705 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii erent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 425 00 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
Rotary 24aabove, 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
13a.Yield(gpm) 18 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 typeC,,lorlrle 73OJo 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