GW1-2021-03732_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
DERRICK HEATH SAWYERS FROM TER?(TO ..: ., ; ��. ...,..�...a. . .. ,.K.
FROM O DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number �15�OUTER`GASING for multi-cased ens OR LINER:if.a licable
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS AND SON WELL +1 tt. 98 rL 6.25 i" #21 1 PVC
Company Name 5f&"JNNER.CA$1NG ORTUB1NG°f"e&'tbecmal closed lon
20010121586 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. fa 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'S SLOT SIZE I THICKNESS J MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in
e18.GROUT `
❑Industrial/Commercial ❑Residential Water Supply(shared) '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation „19 SAND/GRASELPACKS Ni likable. �.... 3 w.�.... .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING=I OG attakti additional sheets if
❑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 ft. gg ft. OVER BURDEN
4.Date Well(s)Completed: 07-14-2021 Well ID#
98 rt• 305 rt• GRANITE
5a.Well Location:
Aggressive Properties
99
Facility/Owner Name Facility ID#(ifapplicable) C� <
ft.
1515 Howard Gap Loop, Lot 3 ft. tt. 90
Physical Address,City,and Zip 11.REMAS RK �Henderson 9587970090 ?
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N 07-15-2021
70"1 OFSignature o Cenified Well Contra t
6.Is(are)the weil(s): ❑✓Permanent or ❑Temporary By signing this form,1 hereby ce fv that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to!the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ojthis 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 one form. SUBMITTAL INSTUCTIONS
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 ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Geater,Raleigh,NC 27699-1617
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11.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 ofi 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) `�
C Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form.within 30 days of completion of
13b.Disinfectiontype: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013
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