GW1-2023-02875_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 DESCRHPTION
Well Contractor Name ft. ft.
4471-A fit
NC Well Contractor Certification Number
r15."Q)i`1 "i ` 11YG,formuIel casetlw'lis Oltct lNl t`i` lid' M i
FROM TO DiAMF,TF.R THiCKNF.SS MATF.RIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 fl, 110 ft- 6.25 in. #21 PVC
Company Name 6;1i!IlV>uR.CSIIYt, r Tt3B719G thetmelclosed-tU
RE22-10063 FROM TO DIAMETER THICKNESS MATERA.AI.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(l.e.County,State,Parlance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.;SGRBE#Y��� , zn � x x a# ,mow c � k .M
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water Supply(single) ft. ft. in.
� E-/ g ppY) PPY( g
❑lndustriaVCommercial ❑Residential Water Supply(shared) r1$1.''GRQUfi A 111;,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ii,; ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
fl. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: fit. fit.
❑Aquifer Recharge ❑GroundwaterRemediation 19:-5i1ND/GffiiX'EIEiiGK'fa"""lica8le � aeM
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To M ta M M ATEAL EPLACEMENT ETHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft fit,
❑Experimental Technology ❑Subsidence Control
�20 DTtILI IN��YiOG.{altach�ad"diHanaT°sheetsffiiecessury
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eainr,hardness,soil/rmk type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 110 fit OVER BURDEN
3-24-2023 110 rt• 665 ft GRANITE
4.Date Weil(s)Completed: Well ID# fit. fit. _
5a.Well Location:
Jeff& Valerie DuRocher fit. fir.
Facility/Owner Name Facility ID#(if applicable) A FI PN
O 023
ft. ft.
962 Wolf Pen Drive Old Fort NC, 28762 Ft. fit
Physical Address,City,and Zip 2tREV1AR[C$u _ � fo- ? s
MCDOWELL 066600161375 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 3-28-2023
Signature ofCettifi a Contractor dF Date
6.is(are)the well(s): [OPermanent or ❑Temporary By signing this fin•m,1 hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C..0100 or 1 SA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repuir,flit out known well construction it furmation and explain the nature uJ the
repair under 421 remarks section or on the back oJ'thi.vJbrm. 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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple byectimh or non-water supply wells ONLY with the suite construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 665 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJjerent(example-3 tit 00'aml 2(a,100) construction to the following:
10.Static water level below top of casing: 150 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 246.For Injection 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 Ceni er,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test- RIG 24c.For Water Supply 8c Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type Amount: 35 well construction to the county health department of the county where
constructed. j
• I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013