GW1-2023-00600_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: `I
14
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. fr. f
4471-A ft. ft.
NC Well Contractor Certification Number t�,.OtfT�t2 CA$trtG far;riuld•cst ertsvetts Olt-1 INEit.
FROM TO DiAMF,TF.R THICKNESS MATF.RiAi,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 27 ft- 16.25 #21 1 PVC
#6.t1Yt+lERfii1$13VGOit<[[tB)1VG j4W 4uthernrai: k 40-f:
Company Name £
375571-1 FROM TO DIAmwrKR THICKNESS I NIATFAIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable urll permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) E�iResidential Water Supply(single) ft• ft. m.
� g/ g PPY) PPY( g
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL FMPLACF.MFNTMF.THOD&AMOUNT
❑lrri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 18.-SAiYDIGRAVEb
❑ FROM TO MATERIAL EMPLACEMENT METHODAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2U DRi tA-NCYlSG:attaeliadLltid"aisheetsifnecessa ...... }
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eater,hardness,soil/rock ry e rain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr. 7 it. OVER BURDEN
12-08-2022 27 fr• 165 fr• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Chris Berry ^A '
Facility/Owner Name Facility ID#(ifapplicable) ft. fr. JQIV O 2023
TBD Tolley Farm Road ft.
Physical Address,City,and Zip 27ME,
�....��E
Madison 9729-32-6538
County Panel 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 12/9/2022
Signature of Cntifi a Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By sibming this form,1 herehy rerti(y thut the Nell(s)hvas(were)constructed in acrar•dcmre
with 15A NCAC 02C..0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or . EINo copy of ills record has been provided to the well oawcr.
Ifthis is a repair,fill out knorrw well cwhstructiwr information find explain the nature of the !
repair under#21 remarks,section or on the back of ibis form. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dt/fer•em(example-3 IV 00'and 2(S..100) construction to the following:
i
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 Servlce;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
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) 25 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Wader i esources Revised August 2013
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