GW1-2021-00235_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:
14.WATER ZONES E`:
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 161 it• 5.25 1O #188 Steel
Company Name
16.INNER CAS ING-,ORTUBING iwthermal'elosed-loo
290155 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State,Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FlResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT 11 METHOD&AMOUNT
❑Irri ation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DR1LLING LOG attach additional-sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 61 R. OVER BURDEN
8-31-2021 61 ft 365 it GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Michael Ensley
Facility/Owner Name Facility iD#(if applicable)
TBD Grassy Creek Rd.
Physical Address,City,and Zip 21.REMARKS, -
Hot Springs 5 8840-65-8681
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 U2141k
08-31-2021
Siignature of erlified Well CcintractolqDale
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certify that the we/!(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy o(this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature o(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 supp[v wells ONLY with the same construction,von 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 warer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5.25 (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) 30 Method of test:
RIG 24c.For Water Supply&Injection Wells:
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: 25
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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