GW1-2023-02881_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:
Kolby Mitchell Sawyers rFRO]%f
%T' a �
1 TO DESCRIPTION
Well Contractor Name
I .
4471-A ft.
NC Well Contractor Certification Number (1 ill 12 'X80 G`fai riraId cased veils TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 92 ft- 16.25 in. #21 PVC
Company Name 64NN£R>Ci1511Y(x`> R;T,l3$11V therriiat�clUsed-tu
RE22-10063 FROM 1'O DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in
3.Well Use(check well use): 17VSCRECNft6,, F� "
Water Supply Well: FROM TO In METER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
JRF
❑hrdu.Strial/COmmeIcial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑itri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rl. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediationl9SANAlGRAYT1sI'AGICif?6
❑Aquifer Storage and Recovery El Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
ZO"DiRd T3NGI UG(attacheaddittau�E 3tteefs`ifiieeessa v
❑Geothermal(Closed Loop) ❑Tracer FRO51 TO DESCRIPTION color,hardness,soil/rmk type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 et. 92 ft. OVER BURDEN
3-10-2023 92 ft- 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
-
5a.Well Location: ft. ft. s•R r ar` :i'
Mark & Christina Jennie APR
Facility/Owner Name Facility ID#(if applicable) ft, ft.
282 Glenhaven Drive Glenhaven Lot 12 MARION, NC ft. ft. r Ir�,rr,_,••: .' -= ' : , Arai
rt
Physical Address,City,and Zip ana.
4Z0tLE1VlARiksA,0.�'w..x� .��
MCDOWELL 161900485945 WELL WAS SELF CERTIFIED
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 3-14-2023
Signature of Certifi Ivell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this firm,1 herehv eerttfy�that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 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.
If this is a repair,fill out known well construction it)jormation oud txplain the nahrre of the
repair trader f12/remark,section or on the back oJ7hisJbrm. 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 ityec•tion or non-water supply wells ONLY with the same cunstruction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ'diJJ rent(example-3 @,2 00'am12(a�100') construction to the following:
10.Static water level below top of casing: 80 (ft-) Division of Water Resources,Information Processing Unit,
If wnler 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ci nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
_ I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013