GW1-2021-01561_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:
h�•K'•:C!•'lfW
DERRICK HEATH SAWYERS
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number '�rnitbe$FTFR � 1F
FROM TO DiAMF,TF.R TAiCKNF.SS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 82 ft- 6.25 in. #21 PVC
Company Name
W20-0549 FROM TO DIAMETER I'HICKN6SS MATEHIAI.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(Le.County,State,Variance,Injection,etc.) �
ft. ft. in.
3.Well Use(check well use): _...
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mlulicipal/Public
❑Geothermal eatin Coolin Supply) BResideatial Water Supply(single)
ft. ft in.
g PPY) PPY( g
❑lndustrial/Commercial []Residential Water Supply(shared)
FROM I TO w MATE.RI-AL EMPLACEMENT METHOD&.AMOUNT
❑hTi ation 0 ft 20 n• BENTONITE PUMPED
Non-Water Supply Well:
ft. I fL.
❑Monitoring ❑Recovery
Injection Well: iL ft.
A
❑Aquifer Recharge ❑Growidwater Remediation 2�J D1 Pe3G1C• "''''"
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater brainage
ft. ft.
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soillrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other•(ex lain under#21 Remarks) 0 f� 82 ft OVER BURDEN
4.Date Well(s)Completed: 02-26-2021 Well ID#
82 430 ft• GRANITE
59.Well Location: 4. ft.
Asa & Gwen McNeely ft. ft.
Facility/Owner Name Facility ID#(if applicable) REGMEED
ft ft.
177 Campground Rd., Old Fort ft. ft.
Physical Address,City,and Zip McDowell 065600913137 Inlormalml 1­10GUbUilluys
County Parcel Identification No.(PIN) DV4R Sedan
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N WA603-01-2021
Sip mrse o 6.98cd Well Con t
6.is(are)the wlll(s): 2Permanent or ❑Temporary
By signing this form.!hereby ce .&that the we.11(s)ww(were)constructed in accordance
with 13A NCAC 02C.0100 nr 1 sA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well cunstructiun information and explain the nature of Ere
repair under#21 remarks secriun or on the back e f 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
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or not-water supply wells ONLY with the same canstrucdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:430 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@2 00'and 2(a,100') Construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: ROTARY 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 27699-16.36
13a.Yield(gpm) 2 Method of test- RIG 24c.For Water Supply&Injection Wells:
�I
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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013