GW1-2022-05293_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple,wells
1.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-cased wells)OR LINER(if a Gcable)
FRONt TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fit. 47 rt. 6.25 i° #21 PVC
Company Name 16.'INNER CASING OR TUBING(geothermal closed-loop)
337837 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fit. in.
List all applicable well permits(i.e.County,State. Variance,ljection,etc.) ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7,F. THICKNESS MATERIAL
fit. fit. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ln'i ation 0 ft'. 20 ft. Bentonite Pumped
Non-Water Supply Well:
it. ft.
❑N4onitoring El Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licablc
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer•Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
rc, fir.
❑Experinhental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothemal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 fit. 7 rt. OVER BURDEN
3-29-2022 47 it 165 fit GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Colton Jones t;t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4370 Grapevine Road Marshall, NC 28753
Physical Address,City,and Zip 21.REMARKS
Madison 9729-74-4854
County Parcel Identification No.(PIN) I '71 n t(G-10t�p i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one W/long is sufficient)
N W 4-20-2022
Log-
Signature of Certified Well Contracto Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
Il this is a repair.Jill out known well construction information and explain the nature of the
repair under#21 remarks section or at 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 if necessary.
For multiple it jec•tion or non-water supply wells ONLY with the saute construction,con can
submit nnc 1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths r/'of?ftrent(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (fit) Division of Water Resources,Information Processing Unit,
!/'water level is above casing,use..+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Fora;GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013