GW1-2021-03734_Well Construction - GW1_20210823

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
4
1.Well Contractor Information: i
KOlby Sawyers p ZONEs
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15 OUTEWCASING for ivriltGcaS wells'OR LINER.:ifza licable ?°
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 tt 6.25 #21 PVC
;;1"6r1NNER CASING OR TUBING eotberuiaLclosed=lori" '
Company Name " `
21100109726 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: et. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft in
3.Well Use(check well use): 17",SCREEN,,,,. c
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS ,a MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. id
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT = a .
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 �AND/GRA L'TACK if:a licable....... .....: - _..' _..3..
MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.:1)RILI ING;LOG fattachaddiiiihal,slieets if recess " ' .......t.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
07/16/2021 60 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
rt. ft.
5a.Well Location:
Eli Dalton
Facility/Owner Name Facility ID#(if applicable)
ft. f[.
112 Jessica LN
Physical Address,City,and Zip 2l'REMA'RICSr arr€tt$3�st?) ..
Henderson 9691206472 �;;,��►'��';;'r�Sr ;ion
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 07/16/2021
ignature of r e Well Contract Date
6.Is(are)the weB(S): ❑✓Permanent or ❑Temporary BY signing this form,1 hereby certifv that the wells)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 E]No cop}'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 I
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,You can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 205 (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 1@100') construction to the following:
10.Static water level below top of casing:
30 Division of Water Resources,Information Processing Unit,
(ft.)
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
24c.For Water Supply&Injectio n Wells:,
13a.Yield(gpm) 1 O Method of test: RIG ,
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