GW1-2021-03733_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:
Kolby Sawyers 14.p1ATER:,ZONEs
PFROIN*lTO DESCRIPTION
Well Contractor Name4471-ANC Well Contractor Certification Number CASING for,muIikis�dtwells OR`LINER ilTO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC 20 ft' 16.25 I" #21 1 PVC
Company Name 16:3NNER1,"CASING OR TUBING euthermal
21100101644 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): -t7.SCREEN k,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
' in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation -,M SA°NDIGRAVEL"PACK if a livable a ...
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. tt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
i20.'DRILLING LOG attach addltiun'al sfieets»i£recess » ..... .... ��°
❑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. 20 rL OVER BURDEN
08/5/2021 20 ft. 225 rt• GRANITE
4.Date Well(s)Completed: Well 1D#
5a.Well Location:
CMH Homes INC
Facility/Owner Name Facility lD#(ifapplicable) n n
803 Battle Creek Rd. tt.
Physical Address,City,and Zip
Henderson 9539958070
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific 'on:
(if well field,one IaUlong is sufficient)
08-5-2021 N W
ignature of a Well Contract Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify 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 ONo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature o(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: 1 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: 225 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 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 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)
20 Methodoftest: RIG 24c.For Water Supply&Injection Wells:!
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Also submit one copy of this formi within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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