GW1-2022-07790_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1C VATER7A1HES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Cenification Number 15,.t5UT1 R:CASLNG for.mulh-casedfvclls OIta IIYER 7f;a heati[e
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 150 ft- 16.25 421 PVC
Company Name
ICINNERCA$ING"ORTIJBINGfkeothermalclqse a-1 otitqz
372368-2 FROM n1AMN: KIt THICKNESS MATERIA
2.Well Construction Permit#: ft. rt. in.
List all applicable m4l permits(i.e.County,State,Variance,Injection,etc.)
ft. Ct. in.
3.Well Use(check well use): 47.SCREEN "
Water Supply Well: FROM To DIAMETER" SLOT SIZE THICKNESS MATERIAL
Ct. ft. in.
❑Agricultural ❑Muni cipal/Public
in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1R=GR0IlT
FROM TO MATERIAL RMPLACF.MFNT METHOD K AMOUNT_
011,; ation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/(:RAVEL PACK:if a' 'itible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DIAIUIING T OG attaelt addltleasl'sheels f.mecess I
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/a k tv a gnin size,etc.l
❑Geothermal(Heatin Coohn Return) ❑Other(explain under#21 Remarks) 0 ft- 150 ft. OVER BURDEN
7-18-2022 150 ft, 405 ft. GRANITE
4.Date Well(s)Completed: Well ID#
(t. ft.
5a.Well Location: '�" '
Travis Fox L; t �..
ft. ft.
Facility/Owner Name Facility ID#(if applicable) -
121 Sunrise Drive ft.
Physical Address,City,and Zip a :. .
21;>REMhRKS ;, t5 -
Madison 9758-22-8843-Portion
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one ladlong is sufficient)
N W V, 0 07/28/2022
Signature of Ceitifi e I Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary y g s / certify (1
B signing g this arm.I hereh'v cern that the Hells teas(were constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C-0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No ropy of this record has been provided to the well owner.
If this is a repair,fill out known well construction infannatiun and explain the nature of the
repair under 421 remarks section or on the back r fthis%arm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply tee/ls ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths ifi4fl rent(example-3(aj200'and 2(q,,100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
7f 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: constnuction 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)
15 Method oftest: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Fora GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013