GW1-2022-03923_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lbrm can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft, ft.
2436-A ft.
NC Welt Contractor Certification Number 15.OUTER CASING for multi-casedwells)OR LINER if a Gcable
FROM TO In
THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 94 ft. 16.25 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-log
354673 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable well permits(i.e.Couniv,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM '110 DIAMETER SLOT SIZE THICKNESS MATF.RIA1,
ft. f[. in.
❑AffrleLIltural ❑Municipal/Public
f. f. in.
❑Gcothernal(Heating/Cooling Supply) ElResidential Water SuPPIY(single)
❑Industrial/Commercial '❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri*ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. t[.
❑N4onitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 94 ft' OVER BURDEN
3-4-2022 94 ft- 265 ft- GRANITE
4.Date Well(s)Completed: Well ID#
it. rt.
5a.Well Location: ft. ft.
Kevin Robinson ft. ft. +hFh
rI1 M� 4s'
Facility/Owner Name Facility ID#(ifapplicabic)
ft. ft.
63 Robinson Hollow Road Marshall, NC 28753 ft. ft.
Phvsical Address,City,and Zip 21.REMARKS
Madison 9707-27-6169
County Parcel Identification No.(PIN) _ v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W W 0 3-7-2022
Signature of ertifted Well Contracto Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I herebv certify 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 E]No copy of this record has been provided to the well owner.
11 Ihi.v is a,(pah-Jill out known well construction information and e.rplain the:nature of the
repair under#2/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.
rot mwDiple injection or non-CA rater supph•wells ONLY with the same construction.you can
submit oneforhn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdr(jerent(example-3 cil200'and 2@I00') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
//tatter/erel 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) 5 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: 25 well construction to the county health department of the county where
constructed. h
Foray GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013