GW1-2021-01562_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:
DERRICK HEATH SAWYERS �14:t�sRs .......y.. ..-z Eaz .
FROM TO DESCRH'TTON
Well Contractor Name ft. ft.
2436-A rt. ft.
NC Well Contractor Certification Number
Y5,"#3ts` it?4ATli for airitl-tssert '. bll ittf"Ifs" Ilca7rte
FROM I TO DIAMETER THICKNESS MATF.RL41.
CLY'DE SAWYERS AND SON WELL +1 ft. 40 ft-. 6.25 #21 PVC
Company Name
SW20-0323 FROM DIAMF,rF.R THICKNESS MATERIAL
2.Well Construction Permit#: ' ft. ft. in.
List'rdl applicable cell permits(i.e.County,State,Yar•iance,Injection,etc:) in.
3.Well Use(¢heck well use): 9 kEV .' .. ....is .....:... ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public A. in.
❑Geothermal(Heating/CoolingSupply) BResidential Water Supply(single) ft. ft' fin•
PP Y) PP Y g
❑Industrial/Commercial Residential Water Supply(shazed) " OTIT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Teri ation 0, ft. 20 fr BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge 0GroundwaterRemediation .S4D14RtAL.PAK='I #` "fie -
�x
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery; ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft, fr.
❑Experimental Technology ❑Subsidence Control
" i,attaatisad+3ltlafTrc_ecetsst -------------
❑Geothermal(Closed Loop) ❑Tracer FROM TO• DESCRIPTION color,hardnes soft/a k type. rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 0 fr OVER BURDEN
ft. fr.
4.Date Well(s)Completed: 02-24-2021 Well ID#
40 - 145 ft GRANITE
5a.Well Location: ft. ft.
Rethel Crisp Hoyle/Holloway/KenttCrossland ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
RECEIVED
315 Moffitt Church Rd.,i Old Fort ft. ft. MA
R X
Physical Address,City,and Zips v
McDowell 065900532936 Information Processing
County Parcel Identification No.(PIN) 1UVVR Section
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 03-01-2021
Signature o Catrfied Well CouXT"
6.Ts(are)thewell(s): 2Permanent or ❑TemporaryBy signing this fenm.1 herehv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well onmer.
If this is a repair.fill out known well construction injortnatiun and explain the nature of the
repair under 921 remarks section or on the back<f this.torm. 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.came construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Its all depths iif dii ferent(example-3(d�200'and 2(a,1001 construction to the following:
10.Static water level below top of casing:
60 (ft) Division of Water Resources,Information Processing Unit,
ff mziler level is above casing.use"+ 1617 Mail Service'Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6.25 (in.) 24b.For Iniection 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(gpm) 10 Method of test: RI G 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 1 5 well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013