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HomeMy WebLinkAboutGW1-2023-02876_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 4471-A NC Well Contractor Certification Number 1t5UTRx+ASirG.formtiiti ea4ed.StiElf3:tSR l I)�7ER if - lieabte`iF :''' FROM TO I DiAMETF.RI THICKNESS MATERIAL CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. S1 ft- 6.25 in. #21 PVC Company Name t'61l�flVERCASf1YG„ORIJBl19G `eotherntaLcloSed=too RE22-10089 FROM TO D1AMFTER THICKNESS MATERIAL 2.Well Construction Permit#: ft. ft. in. List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in. 3.Well Use(check well use): f7.'SCRBEN, Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS hIATERiAL ft. tt. in. ❑Agricultural ❑Municipal/Public ❑Geothermal(Heating/Cooling Supply) E7Residential Water Supply(single) ft. ft. �n• ❑lndustrial/Commercial ❑Residential Water Supply(shared) FROA( TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑hri ation 0 ft. 20 ft- Bentonite Pumped Non-Water Supply Well: rt. ft. Cap Top with Bentonite Chips ❑Monitoring ❑Recovery Injection Well: ❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAMEIi P' -K FROM TO MATERIAL EMPLACEMENT aIETHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control "20:?DRILI1NGr`t3fd:aitactiilddttiau�Tsheats�ifnecessn ��.� ;. .... 3 ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/a k tr a rain size,etc. ❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 81 rt' OVERBURDEN 3-23-2023 81 ft 305 ft GRANITE 4.Date Well(s)Completed: Well ID# ft. ft. 5a.Well Location: Gerrit & Stephanie Topp Facility/Owner Name Facility ID#(if applicable) APR ft, ft. 1 L` 2676 McKenzie Way N Old Fort, NC ft, ft. Ur.': Physical Address,City,and Zip 72-1—fMIEMAR IN i f'. MCDOWELL 065600668326 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 IaUlong is sufficient) V, 03-24-2023 N `,ltC Signature of Cettifi i(Well Contractur I Date 6.is(are)the well(s): RIPermanent or ❑Temporary By sibs»ng this finm,1 hereby certify that the well(s)was(were)constructed in accordance With 15A NCAC 02C.0100 or ISA NCAC 02C.0200 11'ell Conctruc•tion Standards and that a 7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner. If this is a rcpuir,fill out known well construction information and exploit the nature of the repair under#21 remark,section or on the back oJ'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: construction details. You may also attach additional pages ifnecessary. For multiple injection or non-water supply wells ONLY with the same 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'differenI(example-3 @Q 00'and 2(a,100) construction to the following: 10.Static water level below top of casing: 60 (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,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 7 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: 35 well construction to the county health 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