GW1-2021-06222_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Sawyers 4.!WATERZONES ,. ., ....
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
15.OUTER C—'S1$G for multrcased,k6 OR'LE4ER ff'a hca ble z
NC Well Contractor Certification Number FROM X0 Mal
THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 106 ft- #21 PVC
Company Name I&INNER GASING OR T closed-104'
SAS-114W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in•:
❑Agricultural ❑Mtmicipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ¢
❑Industrial/Commercial ❑Residential Water Supply(shared) '-A GROUT'.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation A,SMNDIGRAYEL'PACK , ppili
FR TO OM EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier'
El Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG titttach addition'kl;sheefs if riecess
❑Geothermal(Closed Loop) ❑Tracey FROM TO DESCRIPTION color,hardness soil/rock type,gnin size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 tt 106 ft OVER BURDEN
05/11/2021 106 ft• 225 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Levi Allen
Facility/Owner Name Facility ID#(if applicable)
50 Wrightsville Rd, Canton ft. ft.
Physical Address,City,and Zipa; a
-;11:REMARKS � .
Haywood 8658-13-1508 �nfioC11; 6.NNI
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifrc 'on:
(if well field,one lat/long is sufficient)
N 05-28-2021
ignature of e i Well Contract Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certifv'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: ❑Yes or EINo 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 021 remarks section or on the back of dJs 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
Ifwater 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 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 tenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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 GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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