GW1-2022-07789_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ibrin can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONESKOlby Mitchell Sawyers FROM a
'1'O DESCRIPTION
Well Contractor Name f[. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,wells)OR LINER(if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 145 ft 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
374157-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
l_is't all applicable urll permits(i.e.CountP,State, Variance,Injection.etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 1'O DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquiler Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Ailuifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑L'xperimental Technology ❑Subsidence Control
211.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION color,hardness,soil/mck type,gnin size,etc.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 45 ft. OVER BURDEN
7-22-22 45 ft• 205 ft. GRANITE
4.Date Well(s)Completed: Well iD#
rt. rt.
5a.Well Location: ft. tt. k a `+y4'
Teresa E. Phillips ft. «•
Facility/Owner Name Facility ID#(ifapplicable) _
ft. ft.
44 Mountain Haven Drive Mars Hill, NC 28754
Prz=QzL11tq Un3
Phvsical Address,City,and Zip 21.REMARKS r
Madison 9757-32-9341
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one hat/long is sufficient)
N w 8/3/2022
Signature oFCertifi Well Contractor Date
fi.Is(are)the well(S): ❑O Permanent or ❑Temporary Br signing this jorm,I hereby certW( that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oflhi.s record has been provided to the well owner.
l/this is a repair,Jill uul known well con.siruction inlormalion and erplain the naaa e njlhe
repair under#21 remarks section or on the back o/7his jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also',attach additional pages if necessary.
Vol multiple injeelion ar nun-outer supple wells ONLY with the same construction,voa can
c+thalit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
17or mn6iple wells list all depths ijdi(Jcrent(example-3 t0200'and 2 a7100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
It uatm level is above easing,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 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) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013