GW1-2023-02852_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Interne I Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers '4tkcs« � *z � ��� « �... ��.
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4471-A ft. ft.
NC Well Contractor Certification Number 15:t)tiT:tRGAStI+[tr forrnuld cased,titts C31t.1:INFR i)a liiatiie
FROM TO DTAMETF.R THTCKNE3S IUATF.RTAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 135 ft- 16.25 in. #21 PVC
Company Name l. .f 11TNRC}A$Kl)&Ttl$111Cr �e0ttermstcitK¢dnt6o c
FROM 1'O DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: MC�CM_3 6 V wlt/I�A ft. ft. in.
List all applicable well 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 I THICKNESS I MATERIAL•
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑hldustriaUCommercial ❑Residential Water Supply(shared) FRO111 TO MATFRTAL EMPLACEMENT METHOD&.AMOUNT
❑ln; ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring' ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19ANli/Cf{t�1?EL:PAGK if a`""tteab7e° <:,.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROf11 TO MATERIAL EMPLACEMENT n1ETHOD
[t, ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 U121GIG T fl attc>s ail8itiatshets:ifueceisnrv" °" "
❑Geothermal(Closed Loop) ❑Tracer MOM TO DESCRIPTION color,hardnes so]Yrmk tv a grain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 tt' 35 ft OVER BURDEN
4-11-2023 35 tt• 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: —
rt. rt.
Nathan Mann&Brittany Blake fc. rr. f K
Facility/Owner Name Facility ID#(if applicable)
2718 Newfound Road Canton NC 28716
v
Physical Address,City,and Zip 7ttTki4t"ARIr
Haywood 8667-89-6689 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latllong is sufficient)
N W va 4-13-2023
Signature ofCertifi a Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I herehr certify that the r+ell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well onner.
If this is a repair,fill out known well construction it formation and explain the nature of the
repair under#21 remark,section a-on the back gl'this./orm. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
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 ij'dijferent(example-3 dl 00'am12@100') construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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,I Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gp )20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this for within 30 days ofcompletionof
PILLS
13b.Disinfection type: Amount• 25 well construction to the county he m alth department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013