GW1-2023-02880_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:
�14:�5?ATEIL�NES.�;
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number YA3�"'Ot1T);tt'G'AStNG:fo�tnulti-ca � efls`.OR17NEtt-iP'a„ tieslsfe �
FROM TO DiAMETF.R THiCKNF,SS MATF.RiAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 100 it. 6.25 #21 PVC
Company Name ,161NNER.0 Sf W,0W '061NG e4theilwnl`os"ed=tub" ku i
W22-10265 FROM '1'O DIAMb F.14 THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable urll permits(i.e.County,State,Variance,Injection,etc.) ft ft. in
3.Well Use(check well use): Vf i',S" <EN.i5'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) tt. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) FROM TO MATF.RiAL F.MPLACFMF.NTMETHOD&AMOUNT
131ni ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. fc. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation14:SAND/GICAVLPACK'fa 'licatile K �
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
s,.2tlTlRtll;)G119t�:�U�'all"aC)l iidilttiu�"a'tslteills if�irecessary�;:,.. ��. "<.:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sof/r k type. rein size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 100 ft. OVER BURDEN
3-14-2023 100 rt• 405 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: _
R&B Enterprises/2020 Builders ft. ft. .. s.::.z tip`Gj:
Facility/Owner Name Facility ID#(if applicable)
39 S Vineyard Village Dr Old Fort, NC 28762 ft. ft. APR 1 9 -
023
Physical Address,City,and Zip 2f RENTAR[(5xr . tTb3,�s,y:; ". '
MCDOWELL 066800587698
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaU(ong is sufficient)
03-16-2022
N �,
Signature ofCertiS ell Contractor f Date
6.is(are)the well(s): 2Permauent or []Temporary By signing this form,I herehv certify that the well(s)wvas(were)constructed in accordance
with ISA NCAC 03C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy of this record has been provided w the well owner.
If this is a repair,fill out known well construction informatian and explain the nature of the
repair under#21 remarks section or on the back oJAisJorm. 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:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ'diijfereru(erample-3v 00'and2@1001 construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
Ij'water 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 Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp ) 24c.For Water Supply&Injection Wells:
13a.Yield m 4 Method of test: RIG i
Also submit one copy of this fo1'm within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county heal
h department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water i e;ounces Revised August 2013