GW1-2021-01559_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DERRICK HEATH SAWYERS FROM TO DESCRIPTION
Well Contractor Name fL ft.
2436-A
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 79 fL 6.25 in. #21 PVC
Company Name Bt
RE20-0533 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): -
Water Supply Well: FROM TO DIAMMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft, fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1000 -IT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 tt. 20 ft• BENTONITE PUMPED
Non-Water Supply Well:
fL it.
❑Monitoring ❑Recovery
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fL ft.
❑Experimental Technology ❑Subsidence Control
1BrII!I G' h 1,
❑Geothermal(Closed.Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fa 79 & OVER BURDEN
ft. rt.
4.Date Well 01-15-2021 s)Completed: Well ID#
79 fQ 705 fL GRANITE
5a.Well Location: ft, fL
Luke Ligrani/Brian Anderson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft
RecEIVED
968 Honeycutt Rd., Marion NC ft. ft.
Physical Address,City,and Zip
McDowell 171700587581
t
County Parcel Identification No.(PN infbanv
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
81.98615 N 35.85854 W Lam- 01-15-2021
Signature of Certified Well Contract Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Dv signing this form,I hereby certifv 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 0No copy ofthis record has been provided to the well owner.
If this is a repair,fill out knoum well construction information and explain the nature of the
repair under#11 remarks section or on the back of this 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: 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 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)2 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: 30 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