GW1-2022-05259_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Derrick Heath Sawyers FROMATERZo DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwclls)OR LINER a Geable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 63 ft• 6.25 ' 921 PVC
Company Name 16ANNER CASING OR TUBING(geothermal closedloo )
NRH-262W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. '"'
List all applicable well permits(i.e.Couno,,State. Variance,Ir jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATtRIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling>/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
( b b PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply 18.'GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. 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 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 63 ft. OVER BURDEN
4-15-2022 63 fc• 205 ff• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Clyde & Derrick Sawyers ft. ft.
Facility/Owner Name Facility ID#(if applicable) a t p•�
ft. ft.
7774 Rush Fork Road Clyde, NC 28721 ft. rt. MM
Physical Address,City,and Zip 21.REMARKS
Haywood 8720-95=8369
County Parcel Identification No.(PM)
ib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 4-25-2022
Signature of CeniLed Well Contracto Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby 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 ONo coP),gfthis record has been provided to the well owner.
I(thi.s is a repair.,Jill out known well construction hijbraration and erplain the nature of the
repair under 921 remarks section or on the back o/'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 nndtiple injection or non-water supply wells ONLY with the same construction,you can
submit once form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 530 (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 a 200'and 2 cc 100� construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
{/barer level is above casing,use••+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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)4 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: 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