GW1--05627_Well Construction - GW1_20240916

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information: i
Derrick I-Ieafil Sawyers .:F14 A Rt1on5w3fw T m . _ s . my s
FRONI TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. I
`li3 Otfi'I;RCASINYG.(for=iriniti-caselivclis(0KiTNEftifft p ttatite)" tIMIC
NC Well Contractor Certification Number FROM TO DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 68 ft. 6.25 ji»• #21 Pvc
Company Name a;IK:INNER"eArSft'ORTUI}lA; (garltirmnitosed Iob ) m �`'" ir u t
384333-2 PRONE TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. : in.
List all applicable well permits(i.e.Cowzty,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): , a , 1,
..}7=5f1REEtY�.u���V'.�.;x 4a�+�r.*SRai' MVMfaiz .z;=
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNE.SS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in" ,
T8 G12U1/11.A I y P `1 ' t; .. au� :.,Ff . :^ice, .
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) FRONT TO MATERIAL' F.MPLACENIENT NIETHOD&.'AMOUNT
❑irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation ti2SA9D1C-RI� 1EACf{iapptteiip)eOM .VM k== ,,'S&
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
Itelift(fs'fi3.O OCIiitiaclil;ddriiiiii5"&Ifi•if=necessa lMet. MVAR
OGeothermal(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
8-20-2024—Well ID# 68 rt. 165 ft. '
GRANITE
4.Date Well(s)Completed: ft. ft. 1
5a.Well Location:
ft. ft.
CMH HOMES INC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
NORTH SIDE ESTATES LOT 2 MARS HILL, NC 28754 ft. ft.
Physical Address,City,and Zip :2}:1tGMARKS #nA: 4.�`„� s W- ,:,ar''; O.. O T ..s M;.s`;,^ ``s
iMt k h 9768-54-2000 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 8-26-2024
Signature of citified Well Contract Date
6.is(are)the well(s): OPermanent or ❑Temporary I — ..
By shoring i/nfi nr.1 hereby certify'that the well(s)was(were(ratr:71::R(on tnr'ac sprat l„•„
with 15A NCAC 02C.0100 or 15A NCAC OK.0200 Well Consh diL t daTclE.plul t t al,
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to,the well rmnner.
If this is a repair.Jill out known well construction information and explain the nature of the S E P 1 U 2024
repair under#11 remarks section or on the hack of /itrm. 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 pagf�`, ita61 CSt}ly; r,": .VF4 UP.a
For multiple injection or non-water supply wells ONLY with the same construction,you can DthCi u`t
submit one form. cG SUBMITTAL INSTUCTIONS . , '
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdilfer•ent(example-3(r) 00'and 20000') construction to the following: '
J
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If II mer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:, In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this fonn 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
20 RIG 24c.For Water Supply&Injection iWells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount 20 well construction to the county I1eath department of the county where
constructed.
Furor GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013