GW1-2022-07903_Well Construction - GW1_20220831

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
FROM TO DESCRIPTION
Well Contractor Name 1 65ft- 170 ft 10 GPM
NCWC 2150-A 215fL 218 fL 25 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
g FROM
TO fL DR THICKNESS
MATERIAL
Justice well Drilling, INC 0 fL 84 6 1/8 in. DR 21
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
127739 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
ElAgricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling/Coolin Supply) XResidential Water Supply ft' f. in.
( 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 El Recovery
0 fL 21 ft- Easy seal 1 Bag pumped
Injection Well: 82 ft. 84 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 ff 78 fL Dirt ,Rock
8/31/22 78 fL 225 fL Granite Quarts
4.Date Well(s)Completed: Well ID#
ft fL
5a.Well Location: ft
Rebecca Disunno Lot 5 ft fL
Facility/Owner Name Facility ID#(if applicable)
ft ft
253 Farm Loop Rd Banner Elk N.0 ft fL
Physical Address,City,and Zip
21.REMARKS
Avery 173400147674
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
35.15704 N - 81 .85786 W 8/31/22
Signature of Cer ed ell VItractor Date
6.Is(are)the well(s): XPermanent or ❑Temporary By signing this m,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 XNo 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 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: 225 (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@100') construction to the following:
10.Static water level below top of casing: 30 (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 1/4 (in) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
Rotar 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 35 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: C l o ri n e 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