GW1-2021-04664_Well Construction - GW1_20210517

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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: a
K 021 �J4.?WATERZONI ,�..
olby Sawyers
t 4 11 2 FROM TO DESCRIPTION
Well Contractor Name , jtll ft. ft.
4471-A _ y prc,,,;35'n�J
NC Well Contractor Certification Number �tt101{„ [�wJ1 SIB
1S:OUTER CASING for multrcased wells OR LINER if a" licable
FROM TO DIAMETER I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 70 tt• 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING eatbermal closed-loci ,, =
EH-21070 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): I�;SCREENI;
..<
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 .18.GROUT ::-=
pp y(shared) FROM TO,YW MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAWELPACK Ifa lleable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
fe. tt.
❑Experimental Technology ❑Subsidence Control
20.;DRILLING LOG attad-additional sheets if ecese =
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gritin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 70 ft. OVER BURDEN
04/22/2021 70 ft• 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
5a.Well Location:
Ed Bailey
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Rock Springs Rd tt.
Physical Address,City,and Zip 21.<REMARKS- ;i-
Polk P77-73
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifrc 'on:
(if well field,one lat/long is sufficient)
04-23-2021
N W
ignature of e t tp
Well Contract Date
6.Is(are)the well(s): RPermanent 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 END copy of 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#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.
Far 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: 305 (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:
30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service k enter,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 form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013