GW1-2022-07961_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This limn,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. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(ifa able)
FROM TO DIAMETER THICKNESS MATERIAL
C!YDE SAWYERS & SON WELL & PUMP INC +1 ft- 53 ft- 16.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING geothermal closed-loo
100212 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i"•
List all applicable well permits(i.e.Countp,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPP1Y(single) ft. ft. i4•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑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 MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING":LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt• 53 R' OVER BURDEN
6-17-2022 53 rt• 265 rt• GRANITE
4.Date Well(s)Completed: Well TD#
ft. ft.
5a.Well Location: ft. ft.
Kevin Cox/Oakwood Homes
Facility/Owner Name Facility ID#(ifapplicable) ft.
317 Landfill Road Burnsville, NC 28714 ft. Air 2
Phvsical Address,City,and Zip 21.REMARKS
Yancey 085000988469000 Unj!
Countv Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if,vell field,one lat/long is sufficient)
N w W12^11 V.SpbA" 7-1-2022
Signature R Certified Well C6mractoL9 Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,/hereby certify That the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
Il an,i.s a,epair fill out known well construction information and evplain the nature ofthe
repair under#11 remarks section or on the back of des 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 injeelian ur rant iruter suppIr wells ONLY with the sane construction,you can
s„l,li,il on"faruh. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfflerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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:
(ix.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service FCenter,Raleigh,NC 27699-1636
C
13a.Yield m 20 Method oftest• RIG 24c.For Water Supply&Injection Wells:
(gP ) 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.
Fur+at GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013