GW1-2023-02871_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 Fd !4\'ATEItzpNJC£fS'Ry �
FROM TO DESCRIPTION
Well Contractor Name
4471-A
lyot%ceR: s�v+�:to uluAsca7wctts',axrfi�ri�Xirgllc li'
NC Well Connector Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 45 It- 6.25 in. #21 PVC
Company Name I';11�1tVER'iGASf1CG;i1RTlSB11�Cy"` ' ermal:ctosed-t ��'x�� ,
091322-5 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable will 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply chazed)
Pp Y(� FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑ini ation 0
20 ff' Bentonite Pumped
Non-Water Supply Well: ft'
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation .9`:5ANDIGRAVITaPAtK:6 liceto
❑Aquifer Storage and Recovery ❑Salinity Harrier FROM TO bIATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft fr.
❑Experimental Technology ❑Subsidence Control
ZO�DIFItL1NC?iflC>.alta'ch'S�drtiuuats6cets-ifFiceessa" ' .,.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color•hardness s2m''ck tv a rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 5 fr OVER BURDEN
2-28-2023 - 45 ft- 205 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
ft. ft.
Jeffrey Kirsch ft. fr. ,
Facility/Owner Name Facility ID#(if applicable)
ft.
1
Rebel Ridge Road Otto 28763
Lr
Physical Address,City,and Zip 21 REM AR �,s=r M=MW
Macon 6489613904 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 lat/long is sufficient)
N W CX, 3-1-2023
Signature of CertihyWell Contractor Date
6.is(are)the well(s): RPermanent or ❑Temporary By sibiting this form,I herehv certify that the well(s)was(were)constructed in accordance
with 15A NCAC.02C.0100 or 15A NCAC 02C.0200 Well 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 and explain the nature of the
repair under 921 remarks section or on the back of this form. 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: 1 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 one form. G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJJ rent(example-3 al 00'and 2(a.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 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: 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 27699-1636
13a.Yield(gpm) 8 Method of test• RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013