GW1-2022-07928_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This l6rin can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM DESCRIPTION
Well Contractor Name
it. ft.
4471-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 72 ft' 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SW21-0429 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
L i.n all applicable well permits(i.e.Counly.State, Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
ft. I in.
❑Auricultural ❑Municipal/Public
ft. ft.❑Geothermal(Heating/Cooling Supply) 171Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 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)
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aq u i ter Test ❑Stonnwater Drainage
ft. ft.
❑I-_xperimcntal Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrocktype,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft- 72 ft. OVER BURDEN
4-8-2022 72 e• 205 rt• GRANITE
4.Date Well(s)Completed: Well iD#
ft. rt.
5a.Well Location:
k� ..
Shelley Campbell ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. it. r
1
ft.Indian Head Sub Lot 39 Rutherford, NC A�
tt. _
w'-!TQ Uf1tt
Physical Address,City,and Zip 21.REMARKS
Rutherfordton 1643568
Couniv Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(il'well field,one lat/long is sufficient)
06/22/2022
N W Ka i. )
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary Br signing this form,I hereby certiji"that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IFINo copy a(this record has been provided to the well owner.
11*this is a repair.fill oul known well construction in%rmation and erplain the nature ol'the
repair under#2t remarks section or on the back o/'ddsjorn. 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 mahiple iniection or non-water supph•wells ONLY with the same construction.you can
submjl one 160-111. SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-m nwhiple wells list all depths i/dijjcrcnt(trample-3@200'and 2 cil100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
ll hhatcr level is ahove casing,use- 1617 Mail Service rCenter,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) 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. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013