GW1-2022-02900_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: a Zs E r 741c�
This form can be used for single or multiple wells FER 1.Well Contractor Information: ,�
Derrick Heath Sawyers "14.WATER ZONES
FROM '1'O DESCRIPTION
Well Contractor Name ft. ft. O;�Ftt�.i isOG
2436-A
NC Well Contractor Certification Number 15 OUTER CASING formultkased wells OR LINER if a" 'licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 55 tt 5.25 #188 Steel
Company Name z 16.INNER CASING OR TUBING 'ep`tfiermal closed-loop)-
JMQ-205W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
List all applicable well permits(i.e.County,State.Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN .;..
Water Supply Well: FROM TO DIAMETER SLOTSI7% THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,,18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft. 20 ft, Bentofiite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 49.SAND/GRAVELiPACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin sin,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n. 55 ft. OVER BURDEN
12-29-2021 55 ft- 245 ft. GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Bernard W. Ferguson
Facility/Owner Name Facility ID#(if applicable)
Fines Creek Rd., Clyde ft. ft.
Physical Address,City,and Zip `21 REM ARKS
. "`<
Haywood 8712-43-0695
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W Q�N( / 1-4-2022
Signature of enified Well I Con mcto Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form.I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis 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 ofthis 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.
Far 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: 245 (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@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
13a.Yield(gpm)
20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
PILLS
13b.Disinfection type: Amount: 25 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