GW1-2022-06142_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD FO.-InternalUseONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers 14.WATER.ZONES
FROM 'CO 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 Ilcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 126 ft 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
373097-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counq;State. i�ariance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA1,
ft. ft. in.
❑Agricultural ❑Municipal/Public
f. ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri gat ion 0 I' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. rt.
❑Monitoring ❑Recovery
Injection Well: fie. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tc' 26 it OVER BURDEN
5-24-2022 26 rc• 405 rc• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. —�
Sexton Baptist Church ft. ft. _ "L
Facility/Owner Name Facility iD#(ifapplicable) ft. ft..
1606 Hazel Brook Road Marshall, NC 28753 JUN
ft, ft,
Physical Address,City,and Zip Link
21.REMARKS f1iCivetu: n v2 nYi3-.,,c
Madison 9726-87-9667 �' u
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 W 5-31-2022
Signature of certifi Well Contractor Date
6.Is(arc)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certify that the well(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 ONo copy gfthiA record has been provided to the well owner.
ll'lhis is a repair.fill out known well construction it formation and explain the nature of the
repair tondo 421 renmrlu section or on the back oj'thisfonn. 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 multiple injection or non-neater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fQJ&ent(example-3 a 200'and 2 cd100') construction to the following:
10.Static water level below top of casing: 50 Division of Water Resources,Information Processing Unit,
(Heater 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:
(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 13tt.Yield(gym) Method of 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.
Forty GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013