GW1-2022-07791_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO A R''O DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number -.8, 01i ITK9 CASttvG for.iitatd eased wefts OR:L NER if a hcable
FROM TO D►A MF.TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 a• 154 ft. 6.25 in. #21 PVC
Company Name 16.INNER CASiNo OR TUB-I-N(x eptUer mat clpsed 1po
370331-2 FROM DiAMN ER 'THICKNESS MATERIAL
2.Well Construction Permit#:
ft ft. in.
List all applicable oral permits(i.e.Count,State,Variance,Injection,etc.) Ct ft in.
3.Well Use(check well use): i7:SCREEN.=
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) BResidential Water Supply(sin(single) in.
1R.GROUT
❑lndustrial/Commercial ❑Residential Water Supply(shared) =: �>
FROM TO MATERIAL RMPLACEMFNT METHOD&.AMOUNT
❑Teri ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation FRSuANDlGRAVhLPAGIs'il'a Cable -_
MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R
❑Aquifer Test ❑Stomtwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control _
20:DRILLING:l_`OG attic iaditl iiiaL'sheafs ff mcessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soi[(o ktype.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 54 ft' OVER BURDEN
7-19-2022 54 ft• 345 ft• GRANITE
4.Date Well(s)Completed: Well ID# % - _ j�
ft. ft. '^ I $^�
5a.Well Location: ft. ft.
David & Natasha Witt ft. ft. ft.d t, 2 S" 20H
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -,^sue
TBD Old Murray Road, Mars Hill ft. f..L, �urt
ft.
Physical Address,City,and Zip 21,REMARKS
Madison 9769-29-8281 21'of 5.25a,# 188 steel
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 07/25/2022
Signature ofCcitifityVell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this firm.I herehv certify thut the w'eN(s)was(were)constructed in accordance
With 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Conctruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
Ifthis is a repair.fill out known well construction information mnl explain the nature ufthe
repair under#21 remarks section or on the back gftltis%arm. 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 a•non-water supply wells ONL I'with the.came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3(V00'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,
If wnler 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
13a.Yield(gpm) 7 Method of test- RIG 24c.For Water Supply&Injection Wells:
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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013