GW1-2022-03892_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers -FRO„ To DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. E
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ii `li able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 r� 65 ft 6.25 ' #21 PVC
Company Name 16.INNER CASING OR TUBING `eothermal closed-loop)
100109 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Cougy,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM "ro DIAMETER SLOT SIZE THICKNESS MAT'M:RIAL
ft. ft. in•
❑Agricultural ❑Municipal/Public
❑Geothemral(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
It. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG{attach additional sheets'if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,gnin size,etc.) it
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 rc' 65 a' OVER BURDEN
3-24-2022 65 rc• 505 rr• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. f r­wG a n_
Alexandra Galantis
Facility/Owner Name Facility ID#(if applicable) ft. R.
1286 Phipps Creek Road Burnsville, NC 28714 VIZ.=30A
ft, rt.
Physical Address,City,and Zip 21.REMARKS
Yancey 070900477545000
County Parcel Identification No.(PIN)
ib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
03-29-2022
N W
Signature of Certified Well CAtractoig Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certi 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 ENo copy of this record has been provided to the well owner.
/(this is a,epair..lill oul known well construction information and e.rplain the nature gl'the
repair under#21 remarks section or on the back of thisJornv. 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.
Fin nuthiple iniectiun or non-water.supply wells ONLY with the same construction,you can
submil one form. C G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (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@100') construction to the following:
10.Static water level below top of casing: OO (ft) Division of Water Resources,Information Processing Unit,
4 eater 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(gym) 20 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type. PILLS Amount: 35 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