GW1-2021-01504_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOLBY MITCHELL SAWYERS
FROM TO DESCRIPTTFTON
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number 15-.t3U11iE1R,Ci►511+it:.foriiirih cased:=:welts ORiL1fi1lg1t f 1tcSbib:: ::<
FROM TO DIAMETER TITTCKNF.SS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 64 ft. 6.25 #21 PVC
Company Name 14 1Nt�1£R C A$lNfxbR,".!t3B1NCx. 44ttuersi aTctused-lpo
62891 FROM 1O DIAMKTER THICKNESS MATERIAL
2.Well Construction Permit#: fr. (t. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) Ct. ft. in.
3.Well Use(check well use): 17 SCREEN......::. � 3
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THTCKNESS 1\fATERT.AL
❑Agricultural ❑Municipal/Public ft ft to
❑Geothermal (Heating/Cooling Supply) El Residential Water Supply(sin(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -��- RUCtT :::-: ..--�_E
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ti-ri ation 0 ft. 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Trajection Well: ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19,$zSl!JA/DRAELTtACK:'d:8'
FROM TO MATERIAL EbIPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Storntwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
Z0.;1)R11,T311r1'G�IbCY.attiieis a8ditiortal stlerfs:3fariieeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 64 ft• OVER BURDEN
4.Date Well 9/23/20s)Completed: Weil ID# 64 ft• 165 ft• GRANITE
So.Well Location: ft. ft. a W
Gene & Tonya Goforth
ar-
Facility/Owner Name Facility ID#(ifapplicable)
1700 Johns River Loop ft.
Physical Address,City,and Zip E r Y
.2t,:iZEMrlR1'GS..,.--_ _evx- ... - �-...•hlr�}�' .:__: . ....aim_-
Burke ,
County Panel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
-81.67623 N 35.796543 W 01-27-2021
Signature ofCcilificUell Contractor QDate
6.1s(are)the well(s): ❑O Permanent or []Temporary By signing this form,1 herehv certify that the well(s)was(were)constrialed in aceor•damre
with 1 SA NCAC 03C A100 or I5A NCAC 02C.0200 11 ell Corafruc•tion Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction infurmation and explain the nature of the
repair under#21 remarks section or on the back t f this/irrm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-inter supply wells ONLY with the same construction,you can
submit one form. 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 ijdijferent(example-3( 00'unr12(a 100� construction to the following:
10.Static water level below top of casing: 30 (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 Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013