GW1-2021-00199_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I0WATERZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft.
2436-A
OR`T>INER
NC Well Contractor Certification Number
I5:`OUTER'CAS[NG foi multi caseda yells IC' licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 186 t[ 6.25 in. #21 PVC
10JNNER;CASING ORiT.UBIN a ehermafi closed`too
Company Name
NRH-249W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t[. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 37.SCREENz
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public �n.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
-'__ _�.,
FROM E .-
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT '. ,.
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 79:SANDIGRAA'WPACK ita"lica#i1e '..�. �. . ,�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control u,,,
„20:DRILLING;LOG attach'addihonat'sheets'if,gecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft' 86 t[' OVER BURDEN
10-18-21 86 f[. 285 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Autumn Hall
Facility/Owner Name Facility ID#(if applicable)
ft. ft. PEP 13 i
Bald Creek Rd., Clyde
Physical Address,City,and Zip
z21..REMARKSm_:,. . .
Haywood 8649-29-6073
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N w 10/18/21
Signature of er iGed Well CiTntractoig Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby ceriifv 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 KNo 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 we11 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 onefonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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)
10 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: 20 well construction to the county hi alth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013