GW1-2021-01536_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD RECEIVED
For Internal Use ONLY:
This form can be used for single or multiple wells NI AK
U y (1 2021
1.Well Contractor Information: 'V HR A 8
KOLBY MITCHELL SAWWRIStion Processing s.,,�• �
r,TAIQ Sestao FROM TO DESCRIPTION
Well Contractor Name
4471-A h.
NC Well Contractor Certification Number WON=am
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 74 ft. 6.25 in. #21 PVC
Company Name A
20010111492 FROSI TO DIAMETER 'THICKNESS aATERIAL
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):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Murlicipal/Public ft. ft. in
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sin(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) FROM TO MATF.RiAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation I
•\•
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soft/o k type rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 74 fr OVER BURDEN
ft. ft.
4.Date Well d 1-13-21 s)Completed: Well 1D# 74 ft• 165 ft GRANITE
So.Well Location: ft. ft.
LAVONNE FULLE ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
691 DAVE WHITAKER RD ft. ft.
Physical Address,City,and Zip u
HENDERSON 9612838780
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one lat/tong is sufficient)
82.62878 N 35.40986 W 'e"'- 01-18-2021
Si •tore of Certifi W
B signing thisell Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary g j.
y• n-m.I herehr cert 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: OYes or ❑No 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#21 remarks,section or on the back ofthis 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: 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. c C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdiJjereni(example-3(u�00'and 2(a,100') construction to the following:
10.Static water level below top of casing: 40 (ft-) 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: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 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(gym) 5 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 1 5 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