GW1-2022-07963_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fix in can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
_Kolby Mitchell Sawyers FROM TO ft. DESCRIPTION
Well Contractor Name
ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 I'L 75 ft- 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
256095 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable Krell permits(i.e.County,Slate, Variance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal.'Public
❑Geothermal Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
( b PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquitei Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Fxperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)•
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
6-20-2022 75 ft. 165 f. GRANITE
4.Date Well(s)Completed: Well TD#
rt. rt.
5a.Well Location: ft. ft. :: .4 .?k_s' fit_
Ashley Holden ft. ft j
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1124 Byrd Br Road Burnsville, NC 28714 ft ft Unu
Physical Address,City,and Zip 21.REMARKS
Yancey 081200005585000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(il'well field,one lat/long is sufficient)
N W 6-30-2022
Signature of Cerlili Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certiJi that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consawction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IJNo copy gfthi.s record has been provided to the well owner.
ll this is a repair,fill ail known well contraction injbrination and erplain the nature of the
repair tinder 421 renmrks 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 ifnecessary.
For nruhiple injection or non-water supple wells ONLY with the some construction,you can
suhtuit one/ri n. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it chflcrent(example-3 a,200'and 2G100') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
It"m[er 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.c.auger.rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield m 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13h.Disinfection type. PILLS Amount: 20 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