GW1-2021-07439_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolb Sawyers 14.WATERZONES
Y "7��/�� FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number IS.OUTER CASING,for rnulfl-cased iye�is"OR I MR ii a "ticable '
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL PUMP INC +1 fii 20 ft- 6.25 in- #21 PVC'
Company Name 16.INNER CASING OR TUBING eothermal closed loo '
021621-P 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):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft, in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
18.GROUT r >", i
❑IndustriaVCommercial ❑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. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.=SANDIGRAVEL'PACK,(if,apOliciblc ,
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
El Experimental Technology ❑Subsidence Control
20:DRILLINGLOG attach additional sheets it niceisar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrocR type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft. 0 tt. OVER BURDEN
05/19/2021 20 it• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. '
Jennifer Hernandez ft. ft. `sue
Facility/Owner Name Facility ID#(if applicable) rro
89 Sunshine Dr., Franklin ft. it.
Physical Address,City,and Zip' flit
2CREMARKS j
Macon 6586513493
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific 'on:
(if well field,one lat/long is sufficient)
N 05-20-2021
ignature of e1`1141 Well Contract Date
6.Is(are)the well(s): RIPermanent or ❑Temporary By signing this form.I hereby certifv that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or , E]No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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 alsoattach 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: 205 (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,
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
i
13a.Yield m 8 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this forrn within 30 days of completion of
136.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
E
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013