GW1--03586_Well Construction - GW1_20230522

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F TO
FROM TO DESCRCR
IPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15'.but`RRC"A3tNG.forninld cased,`wells.OR'LtNER'ifa hea6le
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 160 ft- 15.25 i #188 1 STEEL
Company Name 16:INl+IER'CA$tNGORTUBl31)(i`i4ufhermalctosedlpo
374343-2 FR051 DIAMET R 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,lniection,etc.) ft ft. in.
3.Well Use(check well use): 14aSGREEN s�.. .... �...
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft, ft. in.
❑Agricultural ❑Municipal/Public
i"
❑Geothermal(Heating/CoolingSupply) ®Residential Water Supply(single)
•
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT MF,T IOD&AMOUNT
❑in; ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediafion 19;'SANDIGRA�!ELP.AGIC tfa'"'cable
FROM TO MATERIAL E51PLACEMFNT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 0011LLINC OG'aftaehadditiurtaistteets:ifatecessarv'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type. rain size,etc.)
❑Geothermal(HeatingJCooling Return) ❑Other(explain under 921 Remarks) 0 fr- 60 ft. OVER BURDEN
4-25-2023 60 fr• 125 tr• GRANITE
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: rt rt `I
David Coatney ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. l .�
2626 Puncheon Fork Road, Mars Hill ft. ft.
•� I t Oi
Physical Address,City,and Zip Li,�tlEM$RKS:'r r,Madison 9851-43-8516 This well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if we0 field,one ladlong is sufficient)
N W V, 0 b, I L 4-26-2023
Signature ofCcitiflifMWell Curtrdctor Date
6.is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I herehr certify that the wrll(s)was(were)constructed in accordance
with 15A NCAC 03C.0100 or 15A NCAC 02C.0200 Well Cons/ruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction infarmatint and explain dte nuture of the
repair under#21 remark,section or on the back of1his 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: 1 construction details. You may also attach additional pages if necessary.
For multiple ityection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
25 9.Total well depth below land surface: 1 (ft.) 24a. For All Wells: Submit this fount within 30 days of completion of well
For multiple wells list all depths tfdilj real(example-3(d2 unrl 2(w100I construction to the following:
10.Static water level below top of easing: 20 Division of Water Resources,Information Processing Unit,
IJ'tnaier level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 20 Method of test: RIG
24c.For Water Supply&Injection)Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to tile county health department of the county where
constructed.
Form G W-1 North Carolina Department of Envirunment and Natural Resources—Division of Water Resources Revised August 2013