GW1-2021-01563_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:
HEATH SAWYERS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a plicable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 71 ft. 6.25 #21 PVC
Company Name 16.INNER CASING'.OR.TITBING(geothermal closed-loop)
SW20-0314 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well 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
ft. ft. in•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fit' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
f�fr
MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier &
❑Aquifer Test ❑Stormwater Drainageft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑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 fit- 71 ft. OVER BURDEN
2-23-2021 71 ft' 325 tt• GRANITE
4.Date Well(s)Completed: Well iD# ft. ft.
5a.Well Location: ft. ft.
MICHAEL&SHEVIA PARKER/CLAYTON ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
RECEIVED
1491 TATERTOWN LOOP NEBO NC 28761 ft. ft. 'y AR X 9 2021
Phvsical Address,City,and Zip 21.REMARKS
MCDOWELL 164900012922 Information Processing Unit
County Parcel Identification No.(PIN) deetlon
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Iat/long is sufficient)
N W -9Q4-4 3-3-2021
Signature of Certified Well Con for Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing[his form,1 hereby ceri�&that the hell(,)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 ElNo copy ofihis record has been provided to the hell owner.
4 this is a repair,fill out known well construction information and explain the nature of the
repair under 11 remarks section or on tire back q/arts 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.
hi,r muhiple injection or non-irater.supply irells ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTU CTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
I•irr multiple we/ls list all depths tfdtferent(example-3 a 200'and 2 cr 100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
//baler level is above casing,use"I" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 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) 4 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