GW1-2022-07731_Well Construction - GW1_20220819

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kolby Mitchell Sawyers 14 R'A1ER7ANES.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
t5,fJUI�RUASING.foriiuln caseells.Olt?LINER-ifa livable
NC Well Contractor Certification Number "' '
FROM TO DIAMETER TRICKNF,SS NTATF.RIAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 26 ft 6.25 � in #21 1 PVC
Company Name 1b.INNER C TUBING;"€otheianat'sfoseti
22100100536 FROM DIAMETER THICKNESS MATERIAL[,
2.Well Construction Permit#: 6 tk. ft. in.
List all applicable well permits(i.e.Counn•,State,Variance,Injection,etc.) ft Ct in
3.Well Use(check well use): „t.1REEN
Water Supply Well: FROM TO DIAMETER SLOTsiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single) tL it in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FRONT TO MATERIAL EMPLACEMENT MF.TROD&AMOUNT
0117i ation 0 ft, 20 ft, Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation "I _SA Si[bi13GGRt�iLPACI.ila " ihte .. �
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20z�f3ILl ING;`'(SG attaeh i ddiflomalsbeEfsaf ecessa ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mk tv e.grain size,etc.)
❑Geothermal(Heating/Cooling Return) Cl Other(explain under#21 Remarks) 0 ft, 26 ft. OVER BURDEN
6-27-2022 26 ft 745 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. -' a
Margaret O'Connor Trustee ft. ft.
Facility/Owner Name Facility ID#(if applicable)
857 Mountain Grove LN
rt ft � n �UD1
Physical Address,City,and Zip 21a:12EMAR4tS=... Wit*'
Henderson 9671094675
County Parcel ldenlification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one[at/long is sufficient)
N W C. 07/28/2022
Signature ofCcrtifliMell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this jor'm.1 herehv certify that the ell(s)was(were)construclerl in accordance
nth I5A NCAC 02C.0100 ar 15A NCAC.02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy of this record has been provided to the well owner.
I(this is a repair,fill ant knuun rvll construction biformation and explain the nature ujthe
repair under 921 remarkv section or on the buck r fthis form. 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 jam. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 745 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well'list all depths i(difjerent(example-3(dj200'and 2(a-100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
I%water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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
1.5 RIG 24c.For Water Supply&Injection:Wells
:
13a.Yield(gpm) 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 health department of the county where
constructed.
Form GW-1 North C:uolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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