GW1-2021-03736_Well Construction - GW1_20210823

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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:
Al .':WATERZONES
Kolby Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number �15t;0UTEWCASING for muitig iwd eIts OR-LINER if*a lica'ble��`�`"_-•
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 47 ft 6.25 in. #21 1 PVC
r6:.INNER CASIN OR I t313ING, eotliermal closed-166
Company Name - _ =-• --
21120102979 FROM TO MATERIAL DIAMETER THICKNESS MATER
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft ft in
3.Well Use(check well use):
17:�SCREENs,. ,
Water.Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. rt. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fa in:
E l
❑Industrial/Commercial ❑Residential Water Supply(shared) �'18.°GRQ1ITs.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
❑lrri ation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 14 SAND/GRAL3'ACH•rr•a ical3e � `
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING=LOG attach addititinal'sheets
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,timin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 47 rt. OVER BURDEN
07/29/2021 47 fc• 185 tc• GRANITE
4.Date Weil(s)Completed: Well ID#
rt. rt.
5a.Well Location:
Bruce Duncan
Facility/Owner Name Facility ID#(if applicable) ft. ft. °
562 Duncan Rd
Physical Address,City,,and Zip
Henderson 9578675383 z1.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifcc on
(if well field,one]at/long is sufficient)
N w 07-29-2021
ignature oftelti Well Contract Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify 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 ONO cony of this record has been provided to the well owner.
!(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: 1 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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 (ft,) 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:1 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
13a.Yield(gpm)
7 Method of test: RIG 24c.For Water Supply&Injection Wells:
, '
Also submit one copy of this form iwithin 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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