GW1-2022-03922_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informatiion:
Derrick Heath Sawyers 14 WATER ZONES ..PT
FROM "r0 DFSCRI PTION
Well Contractor Name ft. ft.
2436-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a`licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 36 ft• 6.25 1 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
335246-3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, 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 MATERIAL
R. ft. in.
❑Agricultural ❑Mtmicipal/Public
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL EMPLACEMENT METHODtt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 36 ft. OVER BURDEN
02-15-2022
4.Date Well(s)Completed: Well iD# 36 ft- 125 ft. GRANITE
rt. ft.
5a.Well Location: rt. rt.
Derek & Brendie Carter ft. ft. �
Facility/Owner Name Facility ID#(if applicable)
f[. ft.
TBD NC 23 HWY, Mars Hill ft. 12
Physical Address,City,and Zip 21.REMARKS `
Madison 9759-90-3410 5.k,Y;Nfiiil
County Parcel Identification No.(PIN) 1 117n I'Ps;. ,-MrlilJ I -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one[at/long is sufficient)
N N o�.�5� " 03-01-2022
Signature of ertified Well Contracto Date
6.Is(are)the wetl(S): ❑✓Permanent or ❑Temporary By signing this form,1 hereby cert�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 ElNo copy ofthis record has heen 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 ofthis 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: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) Method of
20 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• 25 well construction to the county health department of the county where
constructed. f
ForTn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water:Resources Revised August 2013