GW1-2021-06528_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:
Kolby Sawyers 14 WATER ZONES i
FROM 'to DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 1.5.OUTER CASING for multi-cased"wells OR LINER if ao licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 81 ft. 6.25 in #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21100112382 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 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
ft. ft.❑Agricultural ❑MunicipaUPublic in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT °. " ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation J!I.SAND/GRAVEL PACK if a 'lieribk
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL EMPLACEMENT METHOD
tt.
❑Aquifer Test ❑Stormwater Drainage
f[. ft.
❑Experimental Technology ❑Subsidence Control
70:bRILLING IiQG attachaddiridrie[sheets if necess ,. -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 81 ft. OVER BURDEN
09/29/2021 81 ft• 345 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
C. Solesbee LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft. 21
Walt Dr., Lot 4 tt.
Physical Address,City,and Zip Ot+
zj•REMARxs
Henderson 0509188704 ' "• e
R$ec�►o
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)
09-29-2021 N W
ignature of a Well Contract Dale
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 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 of the
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: 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 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 ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 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 Infection Wells ONLY:f In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of 4his 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 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30
PILLS well construction to the county health department of the county where
constructed.
Forst GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013