GW1-2021-06234_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
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1.Well Contractor Information:
Kolby Sawyers za"WATERz
FROM TO DESCRIPTION
Well Contractor Name ft. ft. F
4471-A
NC Well Contractor Certification Number -I5.OUTERCASING'for,nultrcased veils OR'LINER.d'a bcaBie'` � ,.! i,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 76 ft- 6.25 ' 'n-J. #21 PVC
Company Name @16 INNER:CASIIYGORTU8ITVG."?atlfermalclaced-lb .. .`... cl Ps
20100104280 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. gin•
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
RFROM
ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water Supply ft. in.
� P� g PP Y) PP Y
❑lndustrial/Commercial ❑Residential Water Supply(shared)
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation �,.19.SAND/GRAVE PACK(if ho le e �_...a:' ,......
FROM TO MATERIAL EMPLACEMENT METHOD`
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2iF.�DRiLLING;I,{1Gattach'additiou8�,'sheetsifoecess"�'<�_ ....,...._ _.�__._..,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 76 ft. OVER BURDEN
06/26/2021 76 ff• 345 ft. GRANITE
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location:
Aggresive Properties&Development LLC
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
295 Souther Rd., Fletcher «.
Physical Address,City,and Zip 21r"REMARKS
Henderson 9672199205
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitic 'on:
(if well field,one lat/long is sufficient)
N W 07-01-2021
ignature ofCePr4ell Well Contract Date
6.Is(are)the well(s): O✓Permanent or ❑Temporary By signing this form,I hereby certify Ghat 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 /ElNo copy of this record has been provided to the well owner.
If this is a repair,full out known well construction information and explain the nature of the
repair under#21 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: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii Brent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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 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) 3 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 Watei Resources Revised August 2013