GW1-2023-00601_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:
14.R`eTEi�7ANES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name
4471-A `
ft. ft.
15sOti1'�[t+GASING for;iaHrcasedvvells OlttilNEi2 If'ri bcab[e<: `,
NC Well Contractor Certification Number ...3..
FROM I TO DiAMRTF•R TAiCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 «• 1125 ft- 6.25 i" #21 PVC
Company Name t6 ILyNER CASING OR TlIB1NG kOthet ntatSlosetl l0u
373962-2 FROM TO DIAMPIb:R THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. ' t"'
List all applicable well permits p.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DWIETER71 SLOTSIZE I THICKNESS I NIATERiAL
tt. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Coolin Supply) E�IResidential Water Supply(single) ft. ft. in.
(H g/ g pP Y) pP Y( g
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOIMT
❑ltTi ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation
q g FROM
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
�201)RILLING13bC aftaeli.additionalslreatsi6:necessary =: .............. .........
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soiVrmkri a grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 125 fr OVER
7-21-2022 125 ft• 465 ft• GRANITE
4.Date Well(s)Completed: Well ID#
59.Well Location:
Scott&Suzanne Stephenson
Facility/Owner Name Facility ID#(if applicable)
TBD California Creek Road, Mars Hill ft. ft. jA;q 0 6 Z023
Physical Address,City,and Zip 213R�MAT;KS,<:
Madison 9767-24-4639
County Parcel Identification No.(PIN) _ v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 12/09/2022
Signature of Cettifi ell Contractor Date
6.Is(are)the weJl(s): Permanent or ❑Temporary
By signing thin firm,1 herehv certify trio!the well(s)u'us(were)constructed in aceordanre
with ISA NCAC.02C.0100 or ISA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information uml explain the nature of the
repair under#21 remark%section or on the back ofihisJbrm. 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 fora!, q SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:.`t65 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftlijferenr(example-
3( 00'and 2(iw 100) construction to the following: P
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
1j'wuler level is above casing.use"+' 1617 Mail Service:Center,Raleigh,NC 27699-1617
6.25 24b.For In ection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: (in.) 1 g
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 276994636
13a.Yield(gpm)4 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 OW-1 North Carolina Department of Envirunmenl and Natural Resources—Division of Water Resources Revised August 2013
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