Loading...
HomeMy WebLinkAboutGW1-2021-06538_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: K 14.-WATERZONEs olby Sawyers FROM .1'O DESCRIPTION Well Contractor Name ft. ft. 4471-A ft. ft. NC Well Contractor Certification Number 15:OUTER'CASING for molt}cased;wells bR LINER ifa 'licable FROM TO DIAMETER THICKNESS MATERIAL CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft• 6.25 i" #21 1 PVC Company Name 16.INNER CASING OR TUBING '"eothermalsclosed400 r,\i: 21100113907 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. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL ft. ft. in. ❑Agricultural ❑Municipal/Public ft. ft. in. ❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single)❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑lrri ation 0 rt. 20 ft. Bentonite Pumped Non-Water Supply Well: ft. ft. ❑Monitoring ❑Recovery Injection Well: ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage ft. tt. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets:ifnecess ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin size,etc ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 70 ft. OVER BURDEN 09/15/2021 70 ft- 605 ft- GRANITE 4.Date Well(s)Completed: WeII FD# ft. ft. 5a.Well Location: Rocky Hyder Facility/Owner Name Facility ID#(if applicable) 14 Carlisle Dr. Physical Address,City,and Zip Henderson 0509180840 �ej­v,nil �.,3t1a11 Ploc ' n County Parcel Identification No.(PIN) p 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certsc 'on (if well field,one lat/long is sufficient) N N 09-15-2021 ignature of e r tp Well Contract Date 6.Is(are)the well(s): ❑✓Permanent or ❑Temporary Br signing this form,1 hereby certifv that the wells)was(were)constructed in accordance with 15A NCAC 01C.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. If this is a repair,fill out known well construction information and explain the nature of the repair under 921 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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdifferent(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 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.We6 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) 2 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 Water;Resources Revised August 2013