GW1-2022-07792_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM arl TO ltzoNa DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC R'eII Contractor Certification Number t5`f2uTE[tCAStN foKmutdl casedavetts T WLINER.if:a Lcabk k:
FROM TO DTA MRTF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 100 n 6.25 i" #21 1 PVC
Company Name
o."NNER;C.ASING IyR[UB1NG 4pthermaf closed Itib
364330-2 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well pennits(i.e.Coumv,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): a?.-S,CREElV
Water Supply Well: FROM I TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
ft. ft.❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) in.
❑lndustrial/Commercia l ❑Residential Water Supply(shared) 78; R'OI1T _ z
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Gromtdwater Remediation FROM
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. [t.
❑Aquifer Test ❑Stormwater Drainage
ft. f1.
❑Experimental Technology ❑Subsidence Control
20 DI{tL1 NG1OG a[taeti.additi n tsheefs:itaieeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock tv a gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 100 fr OVER BURDEN
7-15-2022 100 ft• 205 fr• GRANITE
4.Date Well(s)Completed: Well
ft. ft.
•e, 9• ;t•re
59.Well Location: ft. ft. `'
n G�k_1 I[=S
Travis Fox
t;
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
100 Sunrise Dr., Mars Hill ft. ft. UM
tritc:cia�:�.sL� r'fc�r�•�:��
Physical Address,City,and Zip 2T RF,MARIfS.•Madison 9758-22-8843
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 V, 0 . 07/21/2022
Signature ofCeitifi a Contrac•toc, Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this fca•m.1 hereby cernifyithut the well(sy was(were)constructed in oceordance
pith 1 SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Nell Cortstruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo ropy ojthis record has been provided to the well omwcr.
If this is a repair.fill out knoun Nell construction information and explain the nature of the
repair under#21 remarks•section or on the back c Jthis/orm. 23.Site diagram or additional Nell 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.came construction,),on can
submit 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
For multiple wells list all depths ifXIferew(example-3(aj200'and 2(a,-100') construction to the following:
10.Static water level below top of casing: 30 (ft.)30 of Water Resources,Information Processing Unit,
If Nnler 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 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,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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.
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Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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