GW1--03593_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers FROM
FROI\I TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft• ft. j
NC Well Contractor Certification Number
R,C�ASW0 for nWtl=caseil3wells:OR°°LINER'ifu heal le yu a
FRO51 TO DUAMF.TER I THUCKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 98 ft. 8.25 in• #21 PVC
.
Company Name ,<t63IlViVE RTC ASIiYGOR,TUBl1�Gl
SW22-0131 FROM TO DIAMETKR 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.Counq State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in,
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
❑IndustriaUCottmtercial ❑Residential Water Supply(shared) 1$ GRViII" < M. "u,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ec. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft•
❑Aquifer Recharge ❑Groundwater Remediation ]9 SilND1GRA1 EL l'r1Glf;H"a""nicotine '
❑Aquifer Storage and Recovery ❑Salinity Banier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20DRILLINC�Isb6,`a"ff�eh"iiili3ii{dir"3�siceets:ititecessarv"� � �"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrmk tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) 0 ft. 98 fr. OVER BURDEN
ft ft
4.Date Well 5-1-2023 s)Completed: Well ID# 98 505 GRANITE
5a.Well Location: ft. ft. a -
Elaine Earley/Taylor Earley ft. ft. MAY
Facility/Owner Name Facility ID#(ifapplicable)
99 Bradley Kelly Dr Old Fort, NC 28762
Physical Address,City,and Zip 21REti7ARlCS ..•��
Mcdowell 064800848186 Well was self certified
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 `I UZPJI�
5-3-2023
Sign tare of ettified Well Contracto Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 herehr rer4f),that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Tell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair fill out knosn well construction information and(explain the nature of the
repair under 1121 remarks section or on the back h f'llds form. 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-seater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'diljerent(example-3 dh 00'and 2(a-100) construction t0 the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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.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) 30 Method of test: 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.
Force GW-1 North Carolina Department of Euviroumenl and Natural Resources—Division of Water Resources Revised August 2013