GW1-2021-00210_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:
Kolby Mitchell Sawyers FR MAZER OI DESCRIPTION
Well Contractor Name ft. ft.
4471—A ft. ft. I
NC Well Contractor Certification Number 413 OUTER"$ING for n ultreasM4etts OR LINER rf 8 7icable;i,
FROM TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt. 52 it. 6.25 i" #21 PVC
Company Name 16?INNER CASIN'G,`ORTUBING eutWrmal closed loti"a s.,,..
21100113205 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State,Variance,1i jection,etc.)
ft. ft. in.
3.Well Use(check well use): a,,47 GREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) lResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) S=GROUT . ""...
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation i'9>AND/GRAo L,PACK(if a'g'cable
FROM MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
El Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
203 oRILLiNG I OG."attach additiiinal sheets if iaecess .,.... 4..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 52 rc. OVER BURDEN
11XQ/21 52 ft 605 ft GRANITE
4.Date Well(s)Completed: Well ID# -
ft.
5a.Well Location:
Michael Riley ft. ft. DEC
Facility/Owner Name Facility ID#(if applicable) ft. ft.
289 Little Creek Rd.
Physical Address,City,and Zip
Henderson 0621060001
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 11/04/21
Signature orCertifi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C A100 or 15A NCAC 01C.0100 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 thisform. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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 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) 1/2 Method of test: RIG i
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. 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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