GW1-2023-02853_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F4=srArl�Rx�1c
FItODI TO DESCRH'TION
Well Contractor Name ft. ft.
4471-A
15:OUTERGASIIVG.for"mWti casedtivells'Oi24fNEft tia"'ticsGte':
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 42 ft. 6.25 in- #21 PVC
Company Name
16 1NNER GASIKG 0R''Ti 1N G,t 1j&t*rxiiiiraiiii&,Q
MCM-638 FROM '1'O DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
List all applicable wvIl pennits(i.e.Couny,State,Variance,Injection,etc.) ft. ft. in,
3.Well Use(check well use): 1t2?R"ECN k
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft• in.
18.1 I Ot1T",.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ln; ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation I9;SANA/GRAVhIrPtlGK'ifa`GIAa
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING-7 t)C.aftacl aidditianal sheets t iiecesse
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Color•hardness,so![/mck ri e rain size,etc.)
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks 0 ft. 2 ft. OVER BURDEN
ft• n
4.Date Well 3-6-2023 s)Completed: Well ID# 42 765 GRANITE
ft. ft.
59.Well Location:
Jeremy Merrell
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2023
Grasty Road Clyde, NC 28721 ft ft
Physical ical Address,City,and Zi fa , 1 f ry 1 I r
Y P
Haywood 8646-16-8705 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 lat/long is sufficient)
N W 3-9-2023
Signature of Certifi ell Contractur l Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this frn•m,1 hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200;Pell 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 Nell construction information and explain the nature of the
repair under 921 remark section or on the back of this iornr. 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 constructivn,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 765 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dijj rent(arample-3 @0 00'and 2(w100) construction to the following:
10.Static water level below top of casing: 140 00 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 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: constriction 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
(gP ) Method of test:8 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this f�orm within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county I ealth department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Wa[er Resources Revised August 2013