GW1-2021-07945_Well Construction - GW1_20210809

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i .
1.Well Contractor.Information:
ft
Kolby Sawyers, wTEI%zovsE. ... � .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number yi15:OUTE1tASING"f6i mulR;casethwelts OTtsLTNER-.Ifa'"'Tieable" .?
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL &PUMP INC +1 ft. 76 ft- 6.25 in. #21 PVC
Company Name 1f%TNNUIZECAS G'OR`Ttt$IriG etrtheriiialAosed loo'" ,. M
SW2O'0434 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.) tt. ft. in.
3.Well Use(check well use): 11'SRET "k ...... .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
ft. % _ in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) hJResidential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential'Water Supply(shared) w
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 14.SANT)IGRA'k31 TACK,rF a lieable ,d�,s ,,m
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
2Q.;IIRIITrTNGOG-attachadditio::aT'stieetcitsuecess�e
❑Geothermal(Closed Loop) .❑Tracer• FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n. 76 rt. OVER BURDEN
06/10/2021 76 ft• 365 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Shirley Brown/Clayton Homes
Facility/Owner Name Facility ID#(if applicable) 'V L_
1022 Randolph Rd., Marion ft.
Physical Address,City,and Zip Ig
21:k1ZEMAItKS ..._ ., .?
McDowell 172100670238 Unit
County Parcel Identification No.(PIN) Inlovi.3 101 v "
C1:QfI
5b.Latitude and Longitude in degrees/minutes/seconds'or decimal degrees: 22.Certitic 'on:
(if well field,one lat/long is sufficient)
N W 06-11-2021
ignature of e i Well Contrac Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Constriction 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,You can,
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 . (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 (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 Injection 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) 3 Method of test: RIG
24c.For Water Supply&Injection Wellsr
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county Health department of the county where
13b.Disinfection type: Amount: 30 constructed. i
Forme GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013