GW1--05236_Well Construction - GW1_20240903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Justice 14.WATER ZONES t
Well Contractor Namc FROM TO DESCRIPTION
2150-A 185 fL 190 ft. 6 GPM
r )r/ t ft. ft.
NC Well Contractor Certification Number 1 IS.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
Justice Well Drilling, INC FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Namc
10054 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C County,State,Variance.etc.) 0 ft. 116 ft. 6 1/8 in' SD R21 PVC
3.Well Use(check well use): ft ft. in,
Water Su 1 Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 0 ft. ft. in.
®Geothermal(Heating/Cooling Supply) x0Residential Water Supply(single) ft. ft. in.
O Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
°Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 1 ft' Hole plug 1 Bag
OMonitoring E3 Recovery 1 ft. 116 ft. Easy seal 10 Bags
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery a Salinity Barrier FROM TO _-MATERIAL EMPLACEMENT METHOD
0Aquifer Test ©Stormwater Drainage ft. ft.
©Experimental Technology 0Subsidence Control ft. ft.
▪Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:08/26/24 Well ID# 0 ft' 106 f' Clay soft rock"sand"
ft. ft.
5a.Well Location:
Robert Babb 106 ft. 225 ft. Granite with Quarts
Facility/Owner Namc Facility ID#(if applicable) ft. ft.
177 Havnaers Point Circle ft. ft.
Physical Address,City,and Zip ft. ft.
Rutherford 064392509 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (:rnr iieri C
(if well field,one lat/long is sufficient) ]0. rtitication:
.
35.445185 N -82.1919571 W 08/26/24
1,4,6t
6.Is(are)the well(s)OPermanent or OTemporary Signature 'crtitied ell C urar Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or fl No with 15.4,VCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that t
If this is a repair,fill out known well construction information and explain the nature of the <OPt of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wel
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of wel
For multiple wells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing:50 (ft.) Division of Water Resources,Information Processing Unit,
If tinter level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24.
Rotaryabove,also submit one copy of this form within 30 days of completion of wel
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) 6 Method of test:Air 24c. For Water Supply& Iniection Wells: In addition to sending the form t
the address(es) above, also submit one copy of this form within 30 days o
13b.Disinfection type: Clorine Amount: 8 OZ completion of well construction to the county health department of the count
where constructed.