GW1-2021-06233_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1►
1.Well Contractor Information: *iN
DERRICK HEATH SAW �i.C/ "��FRON'ATERZ°NEB R
.�a f���+•`� FROM 'r0 DESCRIPTION
Well Contractor Name 1� C+ w t ft. ft
2436-A P�C� t�Ge>v5o� tt. ft.
NC Well Contractor Certification Number 1� �ErJ� `15.0UTER CASING for multi cased wells OR,LiNER if a licable
d�_\� FROM TO DIAMETER 'THICKNESS MATERIAL
CLYDE SAWYERS AND SON�D` +1 ft. 189 rt. 6.25 '" #21 1 PVC
Company Name _,16.INNER CASING OR TUBING. ebthermat closed too
20010121582 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County.State, Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): M
x47:SCREEN ,,-
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑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. tt.
❑Experimental Technology ❑Subsidence Control
20D12iLLING.L`OG'attach additimiil`sbeetsifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,MI/mck type,gnin she,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 89 ft. OVER BURDEN
ft. ft.
4.Date Well 07-14-2021 s)Completed: Well ID#
89 rt• 485 rt• GRANITE
5a.Well Location:
Aggressive Properties ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1483 Howard Gap Loop, Lot 2
Physical Address,City,and Zip
ZL;REMARKS #;' .
Henderson 9587970026
County Parccl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient)
N W � 07-15-2021
Signature o Certified Well Contra t
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby ce ifv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ojthis 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,von can
submit one form. Q C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) 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 m 2 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 daysofcompietion of
13b.Disinfection type: PILLS Amount: 20 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