GW1-2022-07964_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers FROM ER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a
FROM TO DIAMETER ticable THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 144 ft- 16.25 I #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
100377 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft• in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
in.
❑Agricultural ❑Municipal/Public
in.
❑Geothernal(Heaton Cooling Supply) ]Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 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
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 144 it OVER BURDEN
6-20-2022 144 ft 505 ft GRANITE
4.Date Well(s)Completed: Well iD#
ft. rt.
5a.Well Location: ft. ft.
Octavio Navarro -r .
Facility/Owner Name Facility ID#(if applicable) R. ft. ( r
ft. ft
123 Old Cabin Hill Lane Burnsville, NC A
.
Phvsical Address,City,and Zip lIfer 21.REMARKS v a.- .
Yancey 979900029869000 "'"
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if.yell field,one lat/long is sufficient)
V_a� ) 6-30-2022
N W
Signature of Certifi Well Contractor 6 Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,I herebN certijb that the we/l(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 FlNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisforn. 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 ifnecessary.
For multiple injection or non-water.supplr wells ONLY with the sane construction.you can
suhmil one lawn. SUBMITTAL INSTUCTIONS
9.'Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple twe/h list all depths lfdfljerent(example-3 n 200'atd 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
l/water level is above easing.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
1
13a.Yield(gpm) 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.
4
Porno GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013