GW1-2021-04679_Well Construction - GW1_20210517

WELL CONSTRUCTION RECORD
a,9
For Internal Use ONLY:
This form can be'used for single or multiple wells \�
1.Well Contractor Information: g021
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r,I 11 ROM TO DESCRIPTION
Well Contractor Name �.�tq}t"1-.�� ft. ft.
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NC Well Contractor Certification Number 15.OUTER' ASIIvG for multreased;weft'OR LINER It ali licable
FROM '. PTO I DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 70 'ft- 6.25 ' In- #21 PVC
Company Name ` -14.4NNER0A9It!IGORTUBING'eoffiermalcliisedloo �y, ,
C\/►/OHO�t 1`+ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J V V `F C7 ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): '17.SGRE)SN� -
Water Supply Well: FROM 4 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.`GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bit ation 0 ft
20 ft- Bentonite Pumped
Non-Water Supply Well: ft. tL
❑Monitoring ❑•Recovery °
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation` 49.,SAND/GRA VE1'1?ACK:'if a kcal le
❑Aquifer Storage and Recovery � ❑ FROM TO MATERIAL EMPLACEMENT METHODSalinity Barrier ft. tt.
❑Aquifer Test ❑Stormwater Drainage
tlExperimental Technology ❑Subsidence Control
-20.DRILLING'LOG.attach additional sheets if:necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solUrock e,"rain size,etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 70 ft' OVER BURDEN
04/19/2021 70 ft• 305 ft• GRANITE
4.Date Wells)Completed: Well ID#
• ft. tL
5a.Well.Location: '• ft. ft.
Mark Aven
ft. ft.
Facility/OwnerName Facility ID#,(if applicable)
ft. ft.
Lot 37', Vineyards Way, Lake Lure
Physical Address City,and Zip
it REMARKS
Rutherford 1644515
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific 'on:
(if well field,one,lat/long is sufficient)
N W 04-20-2021
ignature of a Well Contract Date
6.Is(are),the well(s): Permanent or ❑Temporary By signing this form,I hereby certifv that the well(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 ElNo copy 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 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,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 ifdierent(example-3@200'and 1@100D 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 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm)'10 Method of test: RIG Also submit one copy of this form within 30 days of completion of
13b.DisinfectionGYP e• 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
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