GW1-2023-02877_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kolby Mitchell Sawyers 1R RFaT11tz<iv�s S
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
t�.t3U C]ti m CA5lb1G-forulh,cased svetls.OR: Ett tfa abtc z
NC Well Contractor Certification Number tIN hc
FROM TO DiAMF.TF.R I ITMCKNESS PIATERiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 et. 132 et• 6.25 1 '" 421 PVC
Company Name tb<INNERGASfNGdRTUWNts epfh zniatbtvsetlMo
SW22-10171 FROM 10 DIAmr.W.R 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable urll permits(<.e.Counht State,Variance,Injection,etc.) fit. ft. in.
3.Well Use(check well use): :1?3CRFiEhC..... �:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
[]Agricultural ❑Municipal/Public er• ft• in.
❑Geothermal(Heating/CoolingSupply) BResidential Water Supply(sin(single) er• ft• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) tK."GRQI)T..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hT9 ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. rt. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.:SANDIGRAELPACK<'da "litadle..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fit. TO fit. Eb1 MATERIAL EMPLACENT METHOD
❑Aquifer Test ❑Stormwater Drainage
fit. fit.
❑Experimental Technology ❑Subsidence Control
::2UslyR1LLINC'T�UG:nttaetadi3ltioiiiiFslleefsffnecessary.: ''
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•soil/rmk type. rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 er• 132 fr OVER BURDEN
3-9-2023 132 fr• 245 ft. GRANITE
4.Date Wells)Completed: Well ID# ft. ft.
59.Well Location:
Phillip Morgan/Clayton Homes ft. ft. 1—° '
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. A! 'R S Z023
327 Hunter Dr., Marion ft.
Physical Address,City,and Zip 21:AEMARK$, -,
McDowell 171114338040 This 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 3-10-2023
Signature of Cntifi ell Contractor Date
6.is(are)the well(s): RIPermanent or ❑Temporary y b b f y f (�
B si min�this firm,1 hereb•certi Ilmt the wells was were constructed in accordance
with ISA NCAC 02C.0100 or 1 sA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to tire well owner.
If this is a repair,fill uut knunw well construction infornwtion and explain the nature of the
repair[order 921 remarks section or on the back ofthis Ihrm. 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 onefor•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij different(example-3@200'and 2(ig100) construction to the following:
10.Static water level below top of casing: 180 (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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: RIG 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.
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Fore GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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