GW1-2023-00598_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRo5ATERzONI� ° t DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well CoutmctorCertificationNumber 15 UtiT�R`CAS[NG for:iriulticiiscdcvetls O#11NEft if!ii 1[cable
FROM TO DiAMF,TER THICKNESS MATF.RiAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 81 ft. 6.25 #21 PVC
t6<;IIyNER CAS1vG,OR.eK1Bll\G eothermnicti)sed
Company Name x.• z,s
373018-4 FROM TO DIAMF ER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. ; In
List all applicable well pennits(i.e.County,State,Variance,Injection,etc.)
ft. ft. • in.
3.Well Use check well use):
Water Supply Well: FROM TO MADCETER sLOT SIZ£ THICKNESS _ MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) lResidential Water Supply(sin(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERCAL EMPLACEMENT METHOD&AMOUNT
Oh-ri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediatiott 49,tiSiS�!TDfDRA3�EGPAGi� ff.a'"`ta6]e _
FROM TO MATERIAL EMPLACEMENT DIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2t11f1tTL1ANt13OG attaeti aAditSuutil sheetsiid iecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock ri a grain size,ere.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 81 ft. OVER BURDEN
11-09-2022 81 ft• 205 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
So.Well Location:
Lauren Hobein
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. _r
TBD Snelson Rd. Marshall
f ft. ft.
Physical Address,City,and Zip
21REiHARKS.;�'h. ,__> x. . I
Madison 8797-27-2700 LULi
County Parcel Identification No.(PIN) r .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ✓AV QiBOG
(ifwell field,one tat/long is sufficient) 22.Certification'.
N W C 11/10/2022
Signature ofCettifi ell Contractor Date
6.is(are)the well(s): ❑°Permanent or ❑Temporary By sibming this fani,i herehv certify that the wrll(s)was(were)constructed in accordance
with 15A NCAC 02C..0100 or 15A NCAC 02C.0200 N'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knouu well construction ir!furmation and explain the nature of the
repair under#21 remarla section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to proNide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYWith the saute construction,)ou can
submit oneform. 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 iJ*diJjcreni(example-3(a 'and 2(w100� construction to ale following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service!Ctinter,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
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
i
13a.Yield(gpm) Method of test:
20 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 l,health department of the county where
constructed.
i
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013