GW1-2021-07946_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: E
• i4:WATER"/.O�E$,fzsxe,� .�.3 i»:e.».�,., z� �,Y" �v:��..���St�,»,�a'�u;.
Kolby Sawyers FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15:",ouTER,CASfNG=formultt-cased=vyelts OIt-'I1NE12'•'i "'lieible'.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE,SAWYERS & SON WELL &PUMP INC +1 ft. 83 ft. 6.25 in. #21 PVC
Company Name 16 fiNNER Gi1S IWG,,0R-TUBING eotheritial
SW20-0191 FROM I 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): 2 :SGREEN ,� �'�3
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft: ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommerclal OResidential'Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 rt. Bentonite Pumped '
Non-Water Supply Weil:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation49:SAND/GRAVEL PACK(ifaii
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2(t,''DIiII T LNCi LAC`a#tach.additionai:sfieets ifnecessYA,, .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 83 ft. OVER BURDEN
06/10/2021 83 ft- 505 ft- GRANITE
4.Date Well(s)Completed:' Well ID#,
ft. ft.
5a.Well Location:
Nancy Foster
Facility/Owner Name Facility ID#(if applicable)
253 Celestrial Dr., Nebo ft. ft. UG ti
Physical Address,City,and Zip
McDowell 174000295258
County Parcel Identification No.(PIN) t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certific 'on:
(if well field,one lat/long,is sufficient)
N W 06-1172021
ignature of a Well Contract Date '
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 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 E]No copy,ofthis 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 ott 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi•[ferent(example-3Q200'and 2(a3100') 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 Iniection 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,Undergrotind Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
2 Method of test: RIG 24c.For Water Supply&Injection Wells:
E
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.
Fours GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013