GW1-2023-02876_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