GW1-2021-06231_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 J
1.Well Contractor Information: Elf
14 WATE2E
Kolby Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
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NC Well Contractor Certification Number I$.:,QUTER fA.SING foeniulhfl:a"ETEReUs,O R rta3` It�able
FROM TO DIAMETER THICKNESS MATERIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 103 tt• 6.25 I #21 PVC
Company Name
`,16 INNE1iSGASIING ORTUBING "''tiermai closed=lou' „ ,
21100105835 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fl. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): SGREEIY
Water Supply Well: FROM TO - DIAMETER V SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) FlResidential Water Supply(single) ft ft In
❑IndustriaL/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 20 ft- Bento nite Pumped
Non-Water Supply Well:
tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 09:.SAND/6RAYEL PACK(if,i"`hcable7 7, i�
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control r2p;pRI1LING,)OGt iNacI ailditionajshoets'ifuecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 103 ft OVER BURDEN
06/08/2021 103 ft 345 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
Sa.Well Location: ft. ft.
CMH Homes INC it. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. e1
25 Irwin Lane, Lot 2
Physical Address,City,and Zip S 3
va2Li"'M11R1CS:
Henderson 9578915004 9tlu I �6 vVR��'fio171
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific 'on:
(if well field,one tat/long is sufficient)
N w 06-09-2021
ture o e t ignaf Well Contract Date
6.Is(are)the well(s): 2Permanent 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 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 5No 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 ofthe
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 oneform. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') 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 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
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13a.Yield(gpm)
4 Method of test: RIG 24c.For Water Supply&Injection Wellsc
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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: 30
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources' Revised August 2013