GW1-2021-01532_Well Construction - GW1_20210309

ED
WELL CONSTRUCTION RECORD RECEI
Far lntemal Use ONLY:
This form can be used for single or multiple wells ❑ ��
1.Well Contractor Information: MAR X
KOLBY MITCHELL SAWYER
_..-... _rum- ----
nt—:rmation P�roce t To DESCRH'TTON
Well Contractor Name V y y 11 vMI ft. ft.
4471-A
NC Well Contractor Certification Number 1$--011I2-LiIL+F>i-for iuhi casetl;wells.ORLf1VE(t'`}f itcable* k..
FROM TO DIAMETER TAICKNF,SS n1ATE.M.
CLYDE SAWYERS AND SON WELL +1 rt. 75 ft. 6.25 i" #21 1 PVC
Company Name 1$;N1+1FRCeC [Nf}.OR7<UB1N0. 4ufhierntnTsk+sed-loti`` aE
20100117059 FROM .1'0 DIAMEThR THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) k it in
3.Well Use(check well use):
tf:SCREEIV :
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 7tt•.GR'9113......._ +:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft• BENTONITE PUMPED
Non-Water Supply Well:
t't. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I9.,SA1d3/GRA-1 PA1£ d_d 'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT DIETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control „z
3ti�3f1t1:LL11�t�i;T;OG,attaeli.aadltiur�l'sTteeis.td�iieeessa _:: fit«.. ....::.:.....:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock tv a rain size,etc.)
❑Geothermal(Heatin CooGn Return) ❑Other(explain under#21 Remarks) 0 ft' 75 ft' OVER BURDEN
ft. ft.
4.Date Weil 02/26/2021(s)Completed: Well ID# 75 ft. 285 k GRANITE
5a.Well Location:
Danielle Tullock
Facility/Owner Name Facility ID#(if applicable)
5 Weston Way, Fletcher ft. ft.
Physical Address,City,and Zip y
21.a2EMARILS. -
Henderson 9662276192
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 03-01-2021
wSis- --�ifiedZel Coutritym.
Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fot•m•1 herehv c the well(s)was(were)constructed in acem-dance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 14 ell Constt•uction Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back ojthis farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 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: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it di/ferent(example-3(u�00'and 2(a1001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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
t
13a.Yield(gpm)4 Method of test: RI G 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 1 5 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013