GW1--01154_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Derrick Heath Sawyers FROM TO DESCRIPTION
i ft. ft. I
Well Contractor Name
2436-A ft.— ft. !
NC Well Contractor Certification Number
WOOTtf""CASIIYO(fb ittiIfia eft shellsAiktiNEft:(If'apjlticalite)`'
FROM TO DIAMETER; THICKNESS MATF.R1.4i.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 68 ft• 6.25 I in. #21 PVC
Company Name IONl!ItR Sit f'xw 0I01 lB11\(i( li'it1'makclase 4 P .. _
EH25291 FROM '1'o DIAMETER. 'THICKNESS MATERIAL _ _
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) in
ft. ft.
3.Well Use(check well use): t7 SCREEN .FROM TO DIAMETER „,
_
Water Supply Well: SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in:
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
fL ft. in.
� � g PPY) PPY( g
❑lndustrial/Commercial ❑Residential Water Supply(shared) ROU' ' ' �r MAWI'lFRo RAL rtCE - METHOD&AMOUNT
❑hrigation 0 ft' 20 ft' Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 1 19ix5ANIi/GRAYE 1'i'i'Gk(' }tplieAtile3
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft. I
❑Experimental Technology ❑Subsidence Control 2tl DRILIANCCO•G tandel%a iliti6netsheets:ifiiecessaiv)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 68 ft• ; OVER BURDEN
11-16-2023 68 ft• 145 ft. GRANITE
4,Date Wags)Completed: Well ID#
ft. ft.
5a.Well Location: rt. ft. Pi;;7—' s
Pamela Coggins ft. ft. '-++'�NJ?> :ttor
{
Facility/Owner Name Facility ID#(if applicable) ft. ft. r[_es
3780 Silver Creek Road Mill Spring, NC 28756 ft. ft.
1 9 2024
1
Physical Address,City,and Zip 421, FIVMAIt'S;'; i . ' i'' _ w;
Polk P43-86 Well was Self Certified ti
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) I
N W S 11-29-2023
Signature o Well Coutracto Date
6.Ts(are)the well(s): ❑O Permanent or ❑Temporary By signing this firm,1 hereby cernfy$rut the well(s)was(were)constructed in accordance
with 114 NCAC 02C.0100 or 15A NC4ICA2C.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 information and explain the nature of the
repair under#21 remarks section or on the back of this firm. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. ,1 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 14 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diiffer•ent(example-3 dl 00'and 2(ti inn) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy If 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 1Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 20 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: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013