GW1-2023-00595_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells ;
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1.Well Contractor information:
Mitchell
�A� pY��+ 14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION!
Well Contractor Name ft. ft.
4471-A ft. rt.
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased Nells)OR LINER(if a Geable)
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 160 ft 6.25 !' #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SW21-0343 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List ill applicable well permits(i.e.Couno,,State,Variance,hyection,etc.) ft. ft- in,
3.Well•Use(check well use): `17.SCREEN =.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. '
❑Aquifer Tcst ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.!)KILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 160 ft. OVER BURDEN
1-11-2022 160 ft 465 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft,
Jay & Stephanie Pichard ft. ft.
e.7 L
Facility/Owner Name Facility ID#(if applicable) ft. ft. a
331 S Feather Falls Trail, Old Fort, NC 28762 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mcdowell 063700194850
Countv Parccl Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N W 11-28-2022
Signature ofCertifitYwchi Contactor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary ey signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Consoucdon Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gflhis record has been provided to the well owner.
if this is a repair,-lill nut known well construction it ftrntalion and explain the nature ofthe
repair under#21 remarks section or on the back o/'this form Yo
. 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.
For muhiple injection or non-Crater supply wells ONLY with the saute construction,You can
submit onefnrn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example-3@200'and 1 a 100') construction to the following:
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10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
Illrater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of;this form within 30 days of completion of well
construction to the following:
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12.Well construction method: ROTARY g�
(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) 10 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this foiTnl within 30 days of completion of
13b.Disinfection type: PILLS Amount 35 well construction to the county health department of the county where
constructed. I 11
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Force G W-I North Carolina Department of Environment and Natural Resources-Division of Waterilt0ources Revised August 2013