GW1-2021-01578_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
@r$ 14.WATER ZONES
Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells:OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 110 ft 6.25 #21 PVC
Company Name 16.INNER CASING,OR TUBING(geothermal closed-loop)
S20-0301 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fc 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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
18.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FOM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 f" 20 ft- Bentonite Pumped
Nan-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,erain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 110 ft. OVER BURDEN
12-15-2020 110 ft- 305 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
INFERION PROP/HARRY NORRIS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
112 CREEKSIDE CIRCLE RUTHERFORDTON ft. ft.
Phvsical Address,City,and Zip 21 REMARKS
RUTHERFORD Informntion c
agsing Unit
County Parcel Identification No.(PIN)
DWR Section
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one]at/long is sufficient)
N W ✓ 1-11-2021
Signature of Certified Well Contra t Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jorm,I hereby certify that the ivell(s)was(were)constructed in accordance
with I5A NCAC 01C.0I00 or I5A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 171No copy ofthis record has been provided to the well owner.
l/this is a repair,Jill out known well construction Information and explain the nature of the
repair under tt1l 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: 1 construction details. You may also attach additional pages if necessary.
h'or 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hior multiple wells list all depths ifdt(ferem(example-3 ct 100'and 1@I00') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
//'water level is above casing,use"I" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 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.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.field(gpm) 5 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: 30 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013