GW1-2021-00212_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES i
Kolby Mitchell Sawyers FROM .110 DESCRIPTION
Well Contractor Name ft. ft.
4
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.for multt-casW wells OR LINER if q' icable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 106 ft- 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING "eothermal closed-loop)--
21100107914 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
ft. tt. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E'lResidential Water Supply(single) ft. ft. In
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 20 rr• Bentoriite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK_(if applicable)
x
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
26:bR1LLING•Li{IG.attach additional sheets if'necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 fL 106 it OVER BURDEN
11/05/21 106 it 305 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
MKE Properties LLC ft. ft. DEC 13
20211
Facility/Owner Name Facility ID#(if applicable)
Irwin Lane, Lot 4 fL
Physical Address,City,and Zip 21.REMARKS
Henderson 9578906986
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one[at/long is sufficient)
N W 11/05/21
Signature ofCertifi Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certifv that the we/l(s)was(were)constructed in accordance
With 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy qf this record has been provided to:the well owner.
/(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 at non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 -(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 1@100') construction to the following:
10.Static water level below top of casing: 30 (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
1
13a.Yield(gpm) 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: 20 well construction to the county health department of the countywhere
constructed.
r
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013