GW1-2021-03775_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:
.,WATER ZONES-,
Kolby Sawyers
FROM TO DM SCRIP,TION '
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number &.15.OUTER CASING for multi-cased`wells OR LINER it ii lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 30 ft.
6.25 In• #21 PVC
Company Name 16.,INNER CASING OR TUBING ""eothernial closed400 ;t I"
279700-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State, Variance,h jection,etc.)
ft. ft, in.
3.Well Use(check well use):
°t7;SCREEN
Water Supply Well: FROM TO DIAMETER'_ SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. tt. in.
❑Geothermal (Heating/Cooling Supply) OResidential Water SuPPIY(single)❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT �-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentoriite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,gnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 30 ft. OVER BURDEN
4.Date Well(s)Completed: 08/4/2021 Well TD# 30 ft- 185 ft. GRANITE
ft. ft.
5a.Well Location:
Lars Peterson ft. ft. ,,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. f'121
TBD Anderson Branch Rd., Marshall ft. U
Physical Address,City,and Zip 21.REMARKSf0�
Madison 8787-73-7143
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific on
(if well field,one]at/long is sufficient) •
08-4-2021 N W
ignature ol'CeMil Well Contract Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,1 hereby cerrifv that the we/l(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 ONo copy of this record has been provided to,-the well owner.
If this is a repair,full out known well construction information and explain the nature of due
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 one form. 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 ifderent(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,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:I 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 m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
136.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
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Foray GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013