GW1-2023-01989_Well Construction - GW1_20230227

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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
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FROM TO DESCRIPTION
Well Contractor Name ft. ft. i i
4471-A ft. ft.
NC Well Contractor Certification Number =t;15'ODTER1CA5ttYG'.'for iiiuttl caseifiiuelie:OR G W Eit if"a"`licatite`:::>:=:«`<=��.�F�:
FROM I TO 1 DIAMETER I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 1141 ft- 16.25 #21 1 PVC
Company Name ?;1GZ1NtNER t ASING:OR:TUBINCi:'4uf6eigiehctosed loo
2.Well Construction Permit#:
2022-23977-9-12408 FROM ft. l0 ft. DIANIF.T:R in. 'THICKNESS NIATER1.41.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATER1.41,
❑Agricultural ❑Mtnlicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft. ft. in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) lit IiROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tni ation 0 ft' 20 ft! Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
e.,.
❑Aquifer Recharge ❑GroundwaterRemediation v`19.15AND/G)�AYEGPr1CK d- eable-=:r...
-POnft-
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier❑Aquifer Test ❑Stormwater Drainage❑Experimental Technology ❑Subsidence Controlt`sfiee[s❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color hardness,soil/rock tv a rain size,etc.)
❑Geothermal Heatin Coolie Return ❑Other(ex lain under#21 Remarks 141 ft. OVER BURDEN
141 ft. 185 ft' _: ''
4.Date Well(s)Completed: Z-3O-ZOZZWell ID# r_�-...
ft. ft. ,�, ... a.. a
5a.Well Location: ft. fr. FEB 2, : Z023
Stephens, Louise B
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. �..
615 Buchanan Loop
ft. ft.
Physical Address,City,and Zi _ w>:>.<:,.::.>:>;::;;;:;:z•:•ic>:>;;:;:: r- :- >.a>i• >x::=::::_.;.
Y Y P - :3 ::3�%�s,-_��.;.:>::�,s�;.i..;;.:;:::.i:•,r,•,,:?,°:.��;;� .��sx-:=:-:�
Jackson 7641-30-2624 ` This'well ywas self certify
Counly 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
01/03/2023
Signature ofCcfflfiyWch Contractor Date
6.is(are)the well(s): 2Permanent or ' ❑Temporary By signing this farm,1 herehv rertify that the well(s)was(were)constructed in accordance
isith 1 SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided t6 the well owner.
If this is a repair.fill out known well construction)?formation and explain the nature of the
repair[order f/21 rtmarlo•section or on the back of this 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: construction details. You may also attach additional pages ifnecessary.
For multiple hyection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(V00'and 2@'100) construction to the following: i '
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring.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 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: if
(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 276994636
15 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gp m) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county iea�lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water'Resources Revised August 2013