GW1-2022-06287_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 14.NV
Yam+
KOlby Mitchell Sawyers FRO MATE TO R ZONES DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number IS.OUTER CASING(for multi=cased wells)? LINER if a licabie
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 6o ft 6.25 #21 PVC
Company Name 116.,INNER CASING OR TUBING' eothermal,closed-loo
SW18-012 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): t7.'SCREEN '
Water Supply Well: NFROMTO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal eatin Coolin Su 1 (]Residential Water Su l sin le ft• in,
� � g PPY) PPY( � g )❑lndustrial/Commercial ❑Residential Water Supply(shared) T
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 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 ft. TO MATERIAL EMPLACEMENT METHODtt.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach addid6nahsheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gritin size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ff• 60 ff• OVER BURDEN
11-26-2019 60 ff• 765 ff• GRANITE
4.Date Well(s)Completed: =Well ID#
ft. ft.
5a.Well Location: ft. ft.
Bills MTN/Scott McDowell
ft. tt• s 'v.' ..F,4•s n 'i 4f P . s
Facility/Owner Name Facility ID#(if applicable)
East Windswept Pass d ZZ
Physical Address,City,and Zip 2L REMARKS
Rutherfordton 1651055
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-.
(ifwell field,one lat/long is sufficient)
N `1 06/20/2022
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form,1 Hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No cop),ofthis record has been 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 of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 765 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 240 (ft•) 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) Method of test:
20 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: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Watei Resources Revised August 2013