GW1-2023-02873_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1Q:R*ATEliYZi7Ni Ste, s
Kolby Mitchell Sawyers FRONT TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number
15 0111e1� i1SIlYG'fo"crni H ea'sedaietls dit."LINkCt,'t �catite a�N
FROM TO DTAMF,TF.RjTHTCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 58 ft- 6.25 #21 PVC
- :Company Name 06;IN3YEt2.C-t1 (Kfa OIt201161'N "eotli'in
389389 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f[. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) Ct ft. in
3.Well Use(check well use): 17.:SCREEN ;z � s �
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THTCKNESs MATERIAL
❑Agricultural ❑Mutlicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1R"GROt1T��`"` " � � ~''
FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tni ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
11. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation AV.sAN11jGtttlVET�RAGT{"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. To ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
�2ttTiliIC:L�tNG''UG,attach"addrtiauhlahheelsi£nec"essgry�;'�',��`���,� � ��,;=�,
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,hardness,sotvrock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 58 fr OVER BURDEN
4-5-2023 58 ft 185 fr GRANITE
4.Date Well(s)Completed: Well II)#
ft. ft. _
5a.Well Location: ft. rt.
Mitchell Lusk ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Morlins Acres Marshall, NC 28753
Physical Address,City,and Zip „ � y
Madison 9725-00-9308
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laVlong is sufficient)
N W 0C. 4-11-2023
Signature ofCertifi a Contractor Date
6.is(are)the well(s): 2Permanent or []Temporary By signing this firm,I hereby certify that the well(s)nas(were)constructed in aceardanee
with ISA NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fall out know well construction information and explain the nature of the
repair under#21 remarL-section or on the back oJ'lhis Jbrm. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. O C 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 ii('differenl(example-3(d�00'and 2(a,,100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
if ester 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 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
13a.Yield(gpm) 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Wate i RI sources Revised August 2013