GW1-2023-00616_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. fr.
2436-A fr.
NC Well Contractor Certification Number T --I1113f tLG-forrtnlh casil'we[ts 012=1 i1N °iCa
FROM TO DIAMF.TF.R! THICKNFSS AfATF.RT.4i.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft- 6.25 #21 PVC
Company Name tb IN#±7E[t CeiS(t�tl,ORTI7BlNs. Otheriiiideto5¢lfrtd4' 3� _ ,,," .,x`:
21100124562 FROM TO o1AMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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List all applicable well permits(i.e.County,State,Yariance,Injection,etc.) ft ft ! in
3.Well Use(check well use): 47 EEN
�.... .. k. ... h- ..-.- .x.---
Water Supply Well: FROM ITO DIAMETER I SLOT SIZEI THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in..I
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rri ation 0 fr. 20 ft- BentOnite' Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 1tJ:S IDl�1�l PAU if-
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:7II11Ll l�if, (1G:aitaeh.ad7ltioreaf eafs>if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,so!Yrmk type. rain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks 0 fr' 90 ft• j, OVER BURDEN
12-30-2022 90 fr' 205 fr• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
John Torres
Facility/Owner Name Facility ID#(if applicable) fL ft.
282 Rugby Dr ft• ft. j
Physical Address,City,and Zip
Henderson 9651236867 This wel'I was self certify
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W p/;� �. 12-30-2022
Sign fire of ertified well C(Tntractoa Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By • fy sng min b�this firm,nrm,1 herehv certify that the e�ell()s was were constructed in accordance
with ISA NCAC O7C.0100 or ISA NCAC 02C.0200 Well Conse•uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out knovw well construction information and explain the nature of the
repair under 921 remarks section or on the back of this jbrm. 23.Site diagram or additional well details: —�
You may use the back of this page to provide additions P4 ssltp de4ai[g Dfi wet)
S.Number of wells constructed: construction details. You may also attach additional pages if necesrsaf .
For multiple injection or non-water supply wells ONLY with the same construdion,you can j ""^f'•
submit one form. SUBMITTAL INSTUCTIONS j; JA N 0 i LOZ3
9.Total well depth below land surface: 205 —(ft.) 24a. For All Wells: Submit thisjform within 3Qf .,,af,complction of well
For multiple wells list all depths ifdif erew(example-3(d200"and 2(a.100) construction to the following:
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10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ij'unter level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: JInl 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
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13a.Yield(gpm) 20 Method of test- RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county he i department of the county where
constructed.
Form GW 1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013