GW1-2022-03948_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:
Kolby Mitchell Sawyers 14.+VVATERZONES _ s
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number IS.OUTER CASING for multl•casid wells OR LINER If a lii able
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 38 n. 6.25 '" 421 PVC
Company Name 16 INNER CASING OR TUBING .&thennal closed-loo
21120104876 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,hgection,etc.) ft. R, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA1,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPPIY(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑in; ation 0 rt• 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fa
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LUG attach additionsTsheets if recess -_
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rL 38 ft. OVER BURDEN
3-28-2022 38 ft. 245 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft 1. -
Sharon Pratt/Jessica Kimbrough
ft. rt.
Facility/Owner Name Facility ID#(ifapplicable)
1016 Apple Valley Rd. ft. RT l�
Physical Address,City,and Zip
21REMARKS-; -_ a-
Henderson 9691889043
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N 04/05/2022
Signature ofCcnifilfw0l Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 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 fist all depths ifdierent(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 Iniection 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) Method of test:
7 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this forme within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013