GW1-2021-06539_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
i
Kolby Mitchell Sawyers FROM TER.�o IPA ,.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wwells OR LINER if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 88 ft- 6.25 #21 1 PVC
Company Name `I6'INNER CASING OR TUBING 'ei thei mal closet!44o
21100102201 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.County,State,Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Iri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection WeB: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if uecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) j 0 ft. 88 ft. OVER BURDEN
10/11/21 88 It, 165 ft. GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location: ft. ft.
Andrew Moss
Facility/Owner Name Facility ID#(if applicable) ft. ft. I 202
103 Maddie Lane ft.
Physical Address,City,and Zip
Henderson 20070122408 �I•REMARKS DVV, eci.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `l r7m 10/12/21
Signature ofCeriifi Well Contractor Date
6.Is(are)the weB(s): R Permanent or ❑Temporary By signing this form,I hereby cer•tifv that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Cons(ruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo cony of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of thisform. 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,you can
submit oneform. CC SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(Jerent(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,
lfwater 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
13a.Yield(gpm)
50 Method of test: RIG 24c.For Water Supply&Injection Wells:Also submit one copy of this fo I rm within 30 days of completion of
13b.Disinfection type:
PILLS Amount: 20 well construction to the county liealth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013