GW1-2021-06214_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
WATERZO ES
DERRICK HEATH SAWYERS I4:
FROM TO DESCRIPTT ION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number 15.OUTER,CASiNTG formukr-cased'`wells-ORLINER ita iiii:able
FROM I TO DIAMETER THICKNESS I 'MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft-, 122 ft- 6.25 in. #21 PVC
Company Name 16.,INNER CASING.ORTUBING: cl eothehnal osed-loo
01252021-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): `17,iSCREEN:
Water Supply Well: FROM TO DIAMETER T SLOTSIZE .THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. fL in.
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 tt. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND1G12AYEUPACK if .a lilkabie.',
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
OExperimental Technology ❑Subsidence Control
20 DRtLLING;1©G attach additioii'al slieets'if.necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colorhardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 22 ff• OVERBURDEN
ft. . ft.
4.Date Well 05-18-2021 s)Completed: Well ID#
22 ft- 105 ft. GRANITE
5a.Well Location: ft. ft.
Santeetlah Shores Inc. >a
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Santeetlah Shores, Tract 7
Physical Address,City,and Zip
., .._ i..:..
Graham 565200020092
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
N W S OL 05-18-2021
Signature o Certified Well Cyt6.Is(are)the well(s): ❑OPermanent or ❑Temporary By signing thisform,1 hereb the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑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#21 remarks section or on the back of this 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.
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: 105 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 60 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 Infection 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.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) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the county where
13b.Disinfection type: Amount: 20 �
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013