GW1-2022-09435_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This linni can be used for single or multiple wells
1.Well Contracior Information:
14;WATER ZONES
Kolby Mitchell Sawyers FROM 1'O DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 ft 6.25 ' in #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SW21-0608 FRO\I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ; in.
List all applicable ivell permits(i.e.County,State. Variance,hyection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal Heating Cooling Supply) El Residential Water Supply ft. ft. in.
( � d PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Initiation 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.
Cl Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑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 56 it OVER BURDEN
8-24-2022 56 ft 405 it GRANITE
4.Date Well(s)Completed: Well ID#
�a.Well Location:
Joel Reader/Clayton Homes
Facility/Owner Name Facility iD#(ifapplicable) ft. ft. p
2077
31 Granite Ridge, Nebo, NC 28761
Phvsical Address,City,and Zip 21.REMARKS
McDowell 173100519850
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well field,one lat/long is sufficient)
N N 9-1-2022
on
Signature of Certfi Well Contractor IF Dale
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form,/herebP certJv 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 ONo copy gf1his record has been provided to the well owner.
Ifthis is a rPair,.frll out known well construction hifin•nnation and eTplain the nature ofthe
repair under#21 rentorks section or on the back gl'thisfonn. 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 ifnecessary.
rnr nmdtiple injection or non-crater supplr wells ONLY with the sane construction,you can
submit onefo-in. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
rnr multiple trel/s list all depths tffWfJlcrent(example-3 a 200'and 2G/00') construction to the following:
I
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
11'nzucr level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:l 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) 15 Method of 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: 35 well construction to the county health department of the county where
constructed.
Forman(iW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013