GW1-2023-02059_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 FROM T 1 0 DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number M-yo UT C lViCAS I N Wx(@Eifi i i I iiab li)
FROM I TO DiAMF,TF.R THICKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 145 ft- 6.25 #21 PVC
Company Name
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 248687-2 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) I I
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
DAgricultural OMunicipal/Public in.
DGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) in.
01ndiustriall'Commercial EIResidential Water Supply(shared) 918sGRQ M
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01nigation 0 ft' 20 ft- Bentorifte Pumped
Non-Water Supply Well:
OMonitoring DRecovery
Injection Well: ft. fL
0Aquifer Recharge DGroundwater Remediation ;�'961SANOXMAVEL*PAQ s1firaidiiii4bl6i-R
ElAquifer Storage and Recovery []Salinity Barrier FROM ft, TO MATERIAL I EMPLACEMENT METHOD
0Aquifer Test Ll Stormwaier Drainage
ft. ft.
DExperimental Technology []Subsidence Control
;i",_PJL0NC",a10Ga,1itd _­dijtrQifitrijtil,'04Wce
DGeothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness,soil/mck type.grain size,etc.)
DGeothernial(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 45ft. OVER BURDEN
2-10-2023 45 305 GRANITE
4.Date Well(s)Completed: —Well ID# ft. R.
5a.Well Location:
Viktor Dranchak
Facility/Owner Name Facility ID#(if applicable)
FEB 2, 7.
Chisel Rock Way/Seven Glens lot 67 Mars Hill NC 28754
Physical Address,City,and Zip Un'A H00=1
Madison 9766-98-1151 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 2-13-2023
(.,f -I--
Signature ofCcitifivv ell Contractor `7 Date
6.1s(are)the well(s): 2Permanent or OTernporarry By signing this form,I hereby certify tha't the well(s)was(were)constructed in aceordanve
with 15A NCAC 02C.0100 or 15A NCAC 02C.02000ell Construction Standards and that a
7.Is this a repair to an existing well: DYes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out knuim well construction iijbrination and explain the nature of the
repair under#21 remarks,section or on the back oJ't1dsJbrm. 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305
—(ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depthv i('tiffflei-en t(example.-3(a,)2 00'and 2(w100) construction to the following:
10.Static water level below top of casing:40 —(ft-) Division of Water Resources,Information Processing Unit,
If% ter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:I 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
12.Well construction method: ROTARY construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,!U6derground 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 form'within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
FormGW­I North Carolina Department of Environment and Natural Resources-Division '.esources Revised August 2013