GW1--07545_Well Construction - GW1_20231121

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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:
Derrick Heath Sawyers 4411W TIIVZONES .,,'' ; MW;. # ' .
FROM TO . DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. I 1
NC Well Contractor Certification Number 152Ci(1,IER=Gi1.51N0(formttlticased>ti t153Ott4TNEFtItif'a pllcalile) ;ere
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 52 ft. 6.25 I in. #21 PVC
Company Name 1ti:;INNE1CCA$11 6�'ORT013'IN n'�> oihermalrtosed.loo(i) �, s
OSS-2023-1118 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ' In.
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List all applicable well permits(i.e.County',State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): ?14ZSCREEN ffi i. �`-W 4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
[Agricultural ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) '18:'GROIre ' '� ` 1 "�` `
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
['Irrigation 0 rt• '52 ft Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ['Recoveryft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ['Groundwater Remediation .49l SAN11/CWAVEL Ei1C1C(ifapplieii6le) WA' nk s4''M
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test 0 Stormwater Drainage
ft. ft.
' ['Experimental Technology ❑Subsidence Control x
flO I.11111.1NOi1.UO tattacl add)'lionaril eets iit°iteces4aty .
['Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.)
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft. 52 ft. ; OVER BURDEN
09/19/2023 52 ft• 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. '
Dixie Card ft. ft. NOV ! 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
71 Harvey Osteen Rd., Zirconia, 28790 H. ft. W Ins:.,,..'. icn r�Yf4a ' I-,,"
J_5��
Physical Address,City,and Zip R21 11t1 ARKS ' AS` x "W ;ry #i '`
Henderson 9565286078
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 `l 09/26/2023
Signature of citified Well Contract° Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By ycertify (}
signing r this form.I hereb• that the wells was were constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the,well oxner.
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 form. 23.Site diagram or additional well details:
You may use the back of this page toll 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: 205 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diijereni(example-3)j 00'and 2kijl o0') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If miter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Injection Wells ONLY: In'addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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 Cen ier,Raleigh,NC 27699-1636
(gpm) RIG 24c.For Water Supply&Injection Wells:
13a.Yield 20 Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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