GW1-2023-01995_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers XICZATEIEZONES20i
FROM TO DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number All 5$0 U T MOO'"M W4606 a
FROM TO DIAMETER I THICKNESS MATERIAL
,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 126 ft- 6.25 n. #21 PVC
Company Name 1E,IMAS00"'OR1,6M N
FROM DIAMETER THICKNESS I NIATKRIAL
2.Well Construction Permit#: 369361-1 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS NIATERUL
ElAgricultural OMunicipal/Public in.
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) in.
[]Industrial/Commercial DResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Elli-tigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
olvionitoring ORecovery
Injection Well:
[]Aquifer Recharge 0 Groundwater Remediation iillGlti4lLPAGK iPaP
OAqui fer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT 51ETHOD
0Aquifer Test ElStormwater Drainage
DExperimental Technology ElSubsidence Control
6fidre -ditiag'044
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,solitrock type.grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft 126 ft OVER BURDEN
4.Date Well(s)Completed: 1-9-2023 Well ID# 126 ft 265 ff GRANITE
5a.Well Location:
Derell Ricker
Facility/Owner Name Facility ID#(ifapplicable) FEB
2800 NW US 25/70 Hot Springs, NC 28743 2 2023
7
ft. fL
Physical Address,City,and Zip
Madison 8850-57-5810 Well Was Self Certified—
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattiong is sufficient)
N W 2-10-2023
Signature ofCertifiyW_eContractor I Date
6.Is(are)the well(s): &aPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)(-(instructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200Nell Construction Standards and that a
7.Is this a repair to an existing well: DYes or ©No copy of this record has been provided to the well owner.
Ifthis is a repainfill out known well construction information and explain the nature ofthe
repair under 921 remarla,section or on the back uJ'thisfiirm. 23.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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBNHTTALINSTUCTIONS
9.Total well depth below land surface: 265 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'different(example-3@)2 00'and 2 @ 100) construction to the followmlg:
i
10.Static water level below top of casing:.50 Division of Water Reso,urces,Information Processing Unit,
lfwater level is above casing.use 1617 Mail Service Center,
enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:!,In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of1this 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
ll Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test- RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form in iwithin 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
• constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013