GW1-2021-06232_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kolby Sawyers FROM TO DESCRIPTION
FROM IP TION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number 15. t,A,OUTER $JlNG-" di,.niiltreaw"wellc 072=L1NElt at_a icable
FROM TO DIAMETER ,THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 59 «• 6.25 '" #21 PVC
Company Name »16.::INNER`G SIIVG'4R T'U$1NG' e4thekttist ck4 C4 tv4 a....:
21100102200 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):
1>=SGREE3N
Water Supply Well: FROM TO v DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public [t. ft. in•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) in•
GRO11T,,
❑1ndustrial/Commercial ❑Residential Water Supply(shared)
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT -
❑Irri ation 0 f" 20 ft- Bentonite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑GroundwaterRemediation =Se NDIGR S L;PACK_ifa 'lieahle
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
;;2(F.11R1LLIN��F+OD.atfachail'ditigiial3sheetsifoecess a<
❑Geothermal(Closed Loop) ❑T7acer FROM. I TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 59 ft. OVER BURDEN
06/07/2021 59 rt• 185 rL GRANITE
4.Date Well(s)Completed: Well ID#
rt. tt.
5a.Well Location:
Andrew Moss
Facility/Owner Name Facility ID#(if applicable)
• ft. ft.
45 Maddie Lane ft. ft. A ,
Physical Address,City,and Zip
Henderson 9690408649
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific on
(if well field,one lat/long is sufficient)
N W 06-08-2021
5ignature of e t Well Contract Date
6.Is(are)the weil(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify,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 END copy o(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#11 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 ornon-water supply wells ONLY with the same construction,you can
submit one form. C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1�`� (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@100') construction to the following:
10.Static water level below top of casing: 30 (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 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 iCenter,Raleigh,NC 27699-1636
13a.Yield(gym)
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.
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Watei Resources Revised August 2013
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