GW1-2022-03917_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lin-m can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers FROM '110 DESCRIPTION
Well Contractor Name
ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells)OR LINER(if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 90 ft 6.25 1 #21 1 PVC
Company Nano 16.INNER CASING OR TUBING(geothermal closed-loop)
356335-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
list all applicable well permits(i.e.Counht State, Variance,It jection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAM ETF,R SLOT SIZE THICKNESS MATERIA I.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supple Well: 20 Bentonite Pumped
ft. R.
❑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 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 t` 90 f`' OVER BURDEN
3-21-2022 90 f` 525 f` GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Cole Riddle
tt. rt.
Facility/O"ner Name Facility ID#(ifapplicable) ft. ft.
310 Murphy Edwards Road Mars Hill, NC 28754
Physical Address,City,and Zip 21.REMARKS
Madison 9757-24-3990
County Parcel Identification No.(PIN) APR 12
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(il'well field.one lat/long is sufficient) p �;�•�':ce.,yti'a:;4
N W
TVI Y�.� Q �"fN �i�4, �:0�3`3��'20z'•2'�`;;E;I','
Signature of ertified Well Contracto Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary BY signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IEJNo cunt gfthis record has been provided to the well owner.
!l'this is a repair.fill oul known wrl/construction in/imnalion and evplain the nalure oflhe
repair under#2l rentarks section or on the hack ofthis 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 if necessary.
1=or multiple injeclian or ran-❑nter.cupplr wells ONLY with the scone construction,you can
suhmil on('form. SUBMITTAL INSTUCTIONS
Y.Total well depth below,land surface: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmltiple it ells list all depths i/'di/jcrenl(example-3G300'and 2 0100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
hate,level is above casing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection 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:
0.c.aueer.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(-,pm) Method of
3 test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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