GW1-2022-02912_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: ~ "" '`
This form can be used for single or multiple wells FEB1.Well Contractor Information: r C 2 8 ?07?
Kolby Mitchell Sawyers FROM ER ZONES' ,• r
FROM TO DF.SCRI PTION •' ••J
Well Contractor Name ft• ft. l
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells ORZINER if a licable
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 50 ft 6.25 #21 1 PVC
Company Name
16.INNER CASING OR T17BING" eothermal closed loo M_<......
17120110998 FROM TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,hyection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA I.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. tt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
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 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. OVER BURDEN
12-07-2021 50 ft- 605 it• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
CMH Homes INC
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
46 Evelyns Way, Flat Rock
Physical Address,City,and Zip
31.REMARKS'.'A_-
Henderson 9587952042
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification•
(if well field,one]at/long is sufficient)
N W Y7XI C­U M�l 12/08/2021
SignalureofCertifi Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this form,i hereby certili,that the well(s)was(were)constructed in accordance
with 1 SA 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 ONo copy of this record has been provided to the well owner.
If this it a repair,fill out known well construction information and explain the nature of(he
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: 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 if different(example-3@200'and 2@100') construction to the fallowing:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+„ 1617 Mall 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
13a.Yield 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gpm) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013