GW1-2021-03738_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 6
DERRICK HEATH SAWYERS FROM ER�zONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. '
NC Well Contractor Certification Number 15,OUTER CASING for multi cased welts OR LINER if a 'licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 56 ft 6.25 i" #21 1 PVC
Company Name 7,16.INNER CASING OR T ING'fkeothermal closed4110
20120114081 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State, Variance,brjection,etc.) ft ft in
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER.' `SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) FlResidential Water Supply(single) ft. ft. im
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft BENTONITE PUMPED
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVFLPACK if a linable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
❑Geothermal(Hearin Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 56 ft. OVER BURDEN
ft. rt.
4.Date Well 02-09-2021 s)Completed: Well ID#
56 tt 345 ft GRANITE
5a.Well Location:
Kimzey-Mills LLC
Facility/Owner Name Facility ID#(if applicable)
ft. ft. `
Shep Dr., Lot 4
Physical Address,City,and Zip
^21:REMARM,: ) c
Henderson 9631062593
County Parcel Identification No.(PIN) . �-.3,"",i I �rarJjl
�x r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: r
(if well field,one lat/long is sufficient)
N W 08-20-2021
Signature o Certified Well Contrarit�
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,l hereby cethat 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 qf 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 021 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 a•non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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@100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
p
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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) Method oftest:4 RIG 24c.For Water Supply&Injection Wells::
;
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county hiealth department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013