GW1-2021-03774_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
H Sawyers 14.WATER ZONES
Heath SaW
Y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A f` f` I
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased Wells)OR LINER if a "lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 91 ft- 6.25 #21 PVC
Company Name 16.INNER.CASING OR TUBING eothermal closed-loop)
328065 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
l,ict all applicable yell permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ft. in.
❑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. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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,gmin siu,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. 91 ft. OVER BURDEN
7-27-2021 91 ft• 165 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Crossland Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable) o, r�
1091 Kell Hunter Road Marshall, NC 28753 ft. ft.
Y ft. ft. � •,•,v,
Phvsical Address,City,and Zip 21,REMARKS- tl
Madison 9737-60-2786 A
County Parcel Identification No.(PIN) .i•�,;r^,`.:es•t`;,�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.,C,e/rtificationn:
N W 74," � 8-3-2021
Signature of Certified Well Con c r Date
6.Is(are)the well(S): ©Permanent or ❑Temporary By signing this form,I hereby certify that,the svell(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 71No copy q(this record has been provided to the well owner.
7l dus is a repair,till out known well construction information and explain the nature of the
repatr 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.
hbr multiple injection or non-water supply welts ONLY with the same construction,you can
suhmti one form. SUBMITTAL INSTLiCTIONS
9.Total well"depth below land surface: 165 (g) 24a. For All Wells: Submit this form within 30 days of completion of well
7itr multiple wells list al/depths J cli[jerent(example-3 a200'and 2@100') construction t0 the following:
50 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft-) i
if water level is above caring,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
f
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.anger,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
s
24c.For Water Supply&Injection Wells:
13a.field(gpm) 12 Method of test: RIG Also submit one copy of this form(within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 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