GW1-2022-02917_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: G Ell
p
This form can be used for single or multiple wells R i a
I.Well Contractor Information:
14,WATER ZONES `—
Kolby Mitchell Sawyers FROM TO DESCRIPTION`
fr, tL � 'v r i- v^v.'r:^(J' flit
Well Contractor Name r
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells)OR LINER(if a livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 50 ft- 6.25 in #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
21100108454 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State, Variance,Injection,etc.)
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) E lResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fc. 20 rt. Bentonite Pumped
Non-Water Supply Well:
❑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 ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary):
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 tt 50 tt OVER BURDEN
11-16-2021 50 fr 185 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Chad Cabe ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hutch Mtn Estates lot 11 Fletcher, NC 28732 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Henderson 9662765749
COnnty 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
11-16-2021
Signature of Cerlifi Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary gy signing this form,I hereby certify 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 ENo cony gflhis record has been provided lo'lhe well owner.
I/this is a repaint,lill out known well construction information and explain the nature of the
repair under 021 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: 1 construction details. You may also attach additional pages ifnecessary.
Fur multiple injection or non-water supply wells ONLY with the same construction,you can
SUBMITTAL INSTUCTIONS
submit om-fnrm.
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'di(Jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (fL) 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
13a.Yield(gpm) 8 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013