GW1-2021-06556_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers 1 FRR WATER ZONES RIPTI
OM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER 1ta' livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 42 16.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING:fgeothermal closed-loop)
AKJ-446W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,hyection,etc.) ft ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
fL ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL',PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
,20 DRILLING LOG attach additional"sheets I recess
❑Geothermal(Closed Loop) ❑Trace[' FROM TO DESCRIPTION color,hardness,soil/rock type,rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 2 ft. OVER BURDEN
ft
4.Date Well 10-4-21 42 105 GRANITE
s)Completed: Well ID#
ft. ft.
5a.Well Location:
Fred Hargett ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Woodmore Rd. ft.
Physical Address,City,and Zip 21.REMARKS fiA., f
Haywood 8608-77-5036 p
County Parcel identification No.(PiN) proce$Sln
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: 1n' 6\NR Sect
(if well field,one lat/long is sufficient)
N N 10/5/21
Signature oC ertified Well Ccntructo6lr Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certifv 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 of the
repair under#21 remarks section or an the back of thisform. 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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water 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) 50 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the county where
13b.Disinfection type: Amount: 2� �' P ty
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013