GW1-2021-03773_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
1.Well Contractor Information:
DERRICK HEATH SAWYERS I .:wnTER.zONEs
-. -. ;......, ... .,,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number Pj 5<OU;•ER GAGING-for m6141-aseil*elb"ORI LINER rt a'livable
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS AND SON WELL +1 ft. 86 tt 6.25 in1 #21 1 PVC
Company Name :16:'N ER GAS G—,QR TUBINGI"eathermal:eWed,i0o
332955 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. fa in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
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3.Well Use(check well use): 47.SCREEN." (fir. _
Water Supply Well: FROM TO DIAMETER'' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18:,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 GANliIGRA�rEhPACKi ifa "`lieslile
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERI AL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control L(1G „
2Q:DR11iIiING .attach adddions[:stieets if recess „ �%,�.... ., '. ...
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 86 rt. OVER BURDEN
ft. ft.
4.Date Well(s)Completed: 08-02-2021 Well ID#
86 ft 525 ft GRANITE
5a.Well Location:
Randy & Janice Ratcliff
Facility/Owner Name Facility ID#(if applicable)
961 Bull Creek Rd, Mars Hill
Physical Address,City,and Zip2I
Madison 9737-82-22629
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N `l fVA A. 08-02-2021
Signature o Certified Well Contra t
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby ce l`✓that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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.
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 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifQferent(example-3@200'and 1@100') construction to the fallowing:
10.Static water level below top of casing: 60 (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:1 In addition to sending the form to the address in
ROTARY AIR 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,1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 3 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form ;within i 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
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