GW1-2022-06299_Well Construction - GW1_20220701

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 105 fL 110 fL 5 GPM
NCWC 2150-A 225fL 230 fL 25 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
g F To DIAMETER THICKNESS
MATERIAL
Justice well Drilling, INC 0 n. 21 fL 10
in SCH 4O Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
OM
2.Well Construction Permit#: fL fL
W2-0411 R 1 T 97 DIAMETER
in• SIDRESS MATERIAL PVC
Lust 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. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Coolin Supply) XResidential Water Supply fL ff rn.
( g g PPY) PPY
❑Industrial/Commercial ❑Residential 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 ❑Recovery 0 ft- 80 ft- Easy seal 10 Bags pumped
Injection Well: 64 fL 97 fL 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- 18 ft- Sand lose gravel
4.Date Well(s)Completed: 7/01/22wenlD# 18 fL 75 ft. Lose Rock& Dirt
75 ft 90 % Clay red rock white rock
5a.Well Location: 90 ft- 200 fL Soft Rock with very soft breaks
Kenneth Green 200 ft. 245f. Granite Quarts
Facility/Owner Name Facility ID#(if applicable)
ft ft
5420 Bat Cave Rd Old Fort ft fL
Physical Address,City,and Zip
21.REMARKS
Mcdowell 065700341640
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)
35.56426 N - 82.18471 W 7/01/22
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 information and explain the nature of the
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: 245 (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: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+",1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (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 30 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