GW1--03559_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
R
Kolby Mitchell Sawyers 34MWER:"nNcs
FROM TO DESCRiPTTON
Well Contractor Name
4471-A
NC Well Contractor Certification Number1S 0t1Ti2'Ca1St11 :fiirmald casttaetts°OR"=t iPIER`)32a" ttcabk"
FROM TO DIAMETER THICKNESS NIATF.RI.AL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 110 ft• 6.25 in. #21 PVC
Company Name Mt6 1 464'9 CASIN#r()I TLJBfI�(x,etifLernral:closed IOo` � ..
100621 FROM r0 DIANIF.'r:It THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Ya•iance,Injection,etc.) in
3.Well Use(check well use): i7.S(REN 'x � F.'."
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sin(single) f. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)Shared) 1,48 ORU .9rR=
FROM TO MATERIAL EMPLACEMENT MF,THOiI Bc AMOUNT
❑Ini ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
it. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. tt
❑Aquifer Recharge ❑Grouud`vater Remediation 19:kSAN1)1GKA1rpi1GK- a ihille ? .>a *xy. aj:.
FRONT TO MATERIAL ENIPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 4 M
211�DR11;[;IPiGI;t)G`aitaeliaddtho$uF;`slieetsiiniecessa�v��'��""
El Geothermal(Closed Loop) []TracerFRONI TO DESCRIPTTON color,hardness,soillrock type rain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks 0 ft- 110 ft. OVER BURDEN
4-24-2023 110 ft- 205 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
James Price ft, ft. ' as
Facility/Owner Name Facility ID#(if applicable) ft, ft. - 202
Prices Creek Road Burnsville, NC 28714
Physical Address,City,and Zip xr
Ys tY P ''2$fiREA'TARKS
Yancey 979900630020000 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 4-25-2023
Signature ofCertiS a Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this jrm,i her•ebv certify that the ivell(s)was(were)constructed in accordance
ivith ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standa•dv and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarl-s•.rection or on the back ofthisJbrm. 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 if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit one form. n C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all eleptks ij'dilferent(arample-3@200'and 2(a;100 construction to the following:
10.Static water level below top of casing:4O (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 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
m 13a.Yield ) Method of test: RIG(gP 24c.For Water Supply&InjectioniWells:
Also submit one copy of this fdrin within 30 days ofcompletion of
PILLS
13b.Disinfection type: Amount• 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013