GW1-2021-01564_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ��p
I.Well Contractor Information: REC V
DERRICK HEATH SAWYERS ^1 FROM WATER -
� 711/t FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A on ProcessiR ft, ft.
InT%-J "oD\rJR Section
NC Well Contractor Certification Number 15.OUTER CASING for muIt-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 fr. 151 ft- 6.25 i1 #21 1 PVC
Company Name 16.'INNER CASING OR TUBING(geothermal closed-loop)
W20-0423 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. ft. in.
List all applicable hell permits(i.e.County.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 Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft- BENTONITE PUMPED
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
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 necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sail/rock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 151 ft. OVER BURDEN
ft. ft.
Date Well 1-12-2021 s)Completed: Well ID#
151 ft• 305 ft- GRANITE
5a.Well Location: ft. ft.
VANDERBILT MORTGAGE&FINANCE
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1214 OLD LINVILLE ROAD MARION ft. ft.
Physical Address,City,and Zip 21.REMARKS
McDowell 170600768752
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W7,1, ei 01-20-2021
Signature ot'Certiflea we Ti Contra Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,1 hereby certify 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 ofthis record has been provided to the well owner.
Ij'ilii.s is a repair,Jill out known well construction information and explain the nature ofthe
repair under"21 remarks section or on the back(/'tuns 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.
hbr multiple injection or non-water.supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'different(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
//haler 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
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,rotaiy,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.field(gpm) 6 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: 30 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013