GW1-2021-01558_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOLBY MITCHELL SAWYERS _
FORONIAI TO DESCRH'TTON
Well Contractor Name
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 13--(3ti111tKStr .fotaurit.casetl=wells.bRt iblk"t ` hcatitc>> .,. k.,S ..
FROM TO DIAMF.TF.R THICKNFSS NfATF.RIAI.
CLYDE SAWYERS AND SON WELL +1 ft. 96 ft. 6.25 in. 1 #21 1 PVC
Company Name 1 ,IN!7E&CsSf!!ltrR Ck7Blly 44thetAt)<Ft95et1laast� �...e.. y.----
SW20-0469 FROM DIAMF1'ER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.)
in. ,
3.Well Use(check well use): TERN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single)
❑Industrial/Commercitd ❑Residential Water Supply(shared) g RDCII_ "FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑h-ri ation 0 it. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation _491- ,..-.--
FROM TO MATERIAL EMPLACEMENT METH(1D
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology El Subsidence Control
31i 7#1Eil!1 ,`` .e[taefs.ar1t11ti " aeeesssl
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solll o k tv a gnin size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 96 ft• OVER BURDEN
ft' ft'
4.Date Well 1/19/21 s)Completed: Well ID# 96 ft. 205 ft• GRANITE
5a.Well Location:
JAMES TOMES/OAKWOOD HOMES
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft.
1700 LACKEY TOWN ROAD, OLD FORT
Physical Address,City,and Zip
21,�3�117+4RI�S�.t,.. 4,r .�__�a h,,,,��. - -- - ---•----=-
MCDOWELL
County Parcel Identification No.(PIN) Iriforri.ativn Processinq unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: .;ectlon
(ifwell field,one lat/long is sufficient)
N W Q ,tr` 01-27-2021
Signature of Cat d Well Contrac I to Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this.form,1 hereby certify that the well(s)%vas(were)constructed in accordance
with 15A NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: E]Yes or ❑No 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 921 remarks section or on the back eifthic/orm. 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h For multiple wells list all depts if different(example-3(d�00'and 2(a l00') construction to the following:
10.Static water level below top of casing' 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifunter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.c,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) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount• 20 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