GW1-2022-09437_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.Kolby Mitchell Sawyers FROM ER ZONES
FROM '1'O DESCRIPTION
Well Contractor Name ft. ft.
4471-A
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. 3) ft 6.25 , in #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
376156-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in•
List al/applicable well permits•(i.e.County,State.Variance,hyectioµ etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SI.OTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. It. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FRO31 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rut, 20 it. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft, ft.
❑Experinmental Technology []Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 30 ft' OVER BURDEN
9-14-2022 30 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. it.
5a.Well Location:
ELIZABETH AMMONS ft. ft.
Facifity/Owner Name Facility iD#(ifapplicable) ft. ft. OCT
BAILEY BRANCH ROAD MARS HILL, NC 28754 rut. rut.
Physical Address,City,and Zip 21.REMARKS '""' .ai•y ;�^ r! .r
MADISON 9747-38=1355 ' ��/"!OG v
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
V__a N. ) (.,.xl 9-29-2022
N W
Signature of Certifi Well Contractor Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this fbrrn,I hereby ecru&drat the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0209 Well 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.
ffthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back gl'thisfor„u, 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.
For nndliple igiec•tion or non-warn•suppty wells ONLY with the same construction,,von can
s„bmi,one Ib.,, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths i/'dj&rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
Ificatrr level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:I 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
m 13:t.Yield
(gp ) Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
PILLS well construction to the county ealth department of the county where
13b.Disinfection type: Amount: 20 h
constructed. i
Forme GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013