GW1-2022-05740_Well Construction - GW1_20220609

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 125 ft. 130 u- 2 G P M
NCWC 2150-A 250 u 255 u- 100 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER I THICKNESS I MATERIAL
Justice well Drilling, INC 0 ft 42 fL 10' in. I SCH 40 Steel
Company Name ,1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: SW21-0479 FROM
0 ft. TOfL DIAMETER in. THICKNESS
SDR 21 MATERIAL
PVC
Lust all applicable well permits(i.e.County,State, Variance,Injection,etc.) O
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Coolin Supply) ❑Residential Water Supply fL ff rn.
( g g PPY) PPY
❑Industrial/Commercial RResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 fL Hole Plug 1 Poured
Non-Water Supply Well:
❑Monitoring El Recovery
f1 50 ft- Easy seal 2 Pumped
Injection Well: 94 ft 96 ft Hole Plug 1 Poured
❑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
fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock a rain size,etc.
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 12 fL Sand
4.Date Well(s)Completed: 6/09/22 Well ID# 12 fL 41 ft. Sand lose gravel
41 fL 65 ft Clay
5a.Well Location: 65 fL 90 ft Sand rock very soft
Gundle,Rex and kim C/O Isable Builders 90 fL 130 fL Med to soft brown rock
Facility/Owner Name Facility ID#(if applicable)
McOwenben Pass Twelve Mile Post Lot 2 13o fL 265ft Granite Quarts
ft fL
Physical Address,City,and Zip
21.REMARKS
Rutherford 1654836
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)
35.42085 N 82.14652 W 6/09/22
Signature of Certif Well Co ctor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this form,I hereby certo,that the wells)was (were)constructed in accordance
with 15A NCAC 02C.0100 or•15A NCAC 02C.0200 Well Constrnrction Standards and that a
7.Is this a repair to an existing well: ❑Yes or XNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well constrnrction inf6rmation and explain the nature ofthe
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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mrdtiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/`f,,11 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
Rotas 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: y 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 m 10 0 + Method of test: Air 24c.For Water Supply&Injection Wells:
�p ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Clorine Amount: 73% 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