GW1-2023-02872_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 FROM TO DESCRIPTION
Well Contractor Name ft. fr.
4471-A ft ft
NC Well Contractor Certification Number t�s.:t)U tI ft t ASfNG:fornHi casetEvetls OR':LIIVEit ifa livable a.:.:.. :.
FROM TO DiAMF,TF.R TMCKNFSS I MATFMIA
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 118 ft- 6.25 in• #21 PVC
Company Name t�.-1Nl�TBR'CASt1VG OR.TUBING eathennal s1vS¢d-10# >
389153-2 FROM DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: rt. fr. in.
List all applicable mull permits(1.e.County,State,Ynriance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): A f._B£RB>l!Fa, . r.... .. t.�...... .:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 11[ATERiAt
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) FiResidential Water Supply(single) ft. tt. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) aF1=GROUP ....� _. .... �.........:«.`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tr,; ation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rL Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGItplVEL'PAGK:tf a cable
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20=L11tti,'L11dG IsEIG!attae�adtlltiuitalsheetsad'aidcessary's: ......:::. . ,. .:.::'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock typ&grain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 118 ft OVER BURDEN
4-05-2023 118 ft• 305 fr GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Jerry C Riddle
-Facility/Owner Name Facility ID#(ifopplicable) ft. ft. APH 1 8 • I J3
TBD Morlin Acres Drive ft. ft.
Physical Address,City,and Zip
Marshall 9725-00-9308 Portion
This well was self certified �v...
County n / 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 4-06-2023
Signature of Cettifi ell Contractor Date
6.is(are)the well(s): 17Permanent or ❑Temporary By signing this form.I herehv certify'that the well(s).vas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or JSA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well outer.
If this is a repair•fill out knuun well construction information and explain the nature of the
repair tender#21 remurkssection or on the backofthis_)brm. 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 saute 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 depths if eli ferent(example-3(tt�200'and 2(x,100) construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If ureter 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 Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service.Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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: 35 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